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COPYRIGHT DEPOSIT 



PL I 




Tvupia Prominens Syphilitica.. 



GONORRHOEA, SYPHILIS, 



OTHER VENEREAL DISEASES. 



THEIE SYMPTOMS, TREATMENT, &c. 



WITH PRESCRIPTIONS. 



BY 

SILAS DUREEE, M.D. 






EIGHT COLORED ILLUSTRATIONS. 



PHILADELPHIA: 
P. BLAKISTON, SON & CO., 

No. 1012 Walnut Street. 
1882. 



0^ 






C/^b 1 



Copyright. 

P. BLAKISTON, SON & CO. 

1882. 



TO 



THOMAS C. BRINSMADE, M.D., 



PRESIDENT OF THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, 

WHO, BY HIS UNWEARIED, INTELLIGENT, AND SUCCESSFUL LABORS TO ADVANCE 

THE GREAT INTERESTS OF MEDICAL SCIENCE; BY HIS DIGNIFIED AND 

COURTEOUS DEMEANOR, AND HIS TRUE MORAL EXCELLENCES 

OF CHARACTER, HAS RISEN TO A HIGHLY HONORABLE 

AND EMINENT POSITION IN THE PROFESSION, 

IS CORDIALLY INSCRIBED AS AN EXPRESSION OF GRATITUDE 

FOR VALUABLE INSTRUCTION LONG SINCE RECEIVED, AND AS 

A TOKEN OF WARM REGARD AND FRIENDSHIP, 

BY HIS PUPIL, 

THE AUTHOR. 



PREFACE. 



A few years since, the author of the following pages prepared 
an Essay on " The Constitutional Treatment of Syphilis," which 
was honored by the award of a premium from the Boylston 
Prize Committee of Harvard University. That Essay constitutes 
a large portion of the present volume ; and, although it has been 
modified to a degree that deprives it of its original identity, it 
is believed that its intrinsic merits have been materially en- 
hanced.* 

In the early part of my professional career, I had charge, for 
several years, of the hospital department of a large Charitable 
Institution, in which venereal patients, and those affected with 
blennorrhagic diseases daily presented themselves ; and I have 
now devoted more than thirty years to the therapeutics of 
syphilis and kindred disorders, as they may properly enough be 
termed. From time to time I have tested a great variety of 
remedies, and have pursued, by way of experiment, almost 
every line of treatment that has been brought to notice with 
any claims to favorable regard. But I have found no royal 
plan of accomplishing a speedy or certain removal of the 
maladies under consideration. They will yield to a judicious 
interposition of medical and surgical skill ; and no man, who 
posesses such skill, will confine himself to a few medicinal 

* By a vote of 1826, the Board do not consider themselves as approving the 
doctrines contained in any of the dissertations to which premiums may be ad- 
judged ; and in case of the publication of a successful dissertation, the author 
is considered bound to print this vote in connection therewith. 

A* (v) 



vi PREFACE. 

substances that may have acquired notoriety as specifics, while 
they are endowed with no such qualities. 

The paramount design which I have endeavored to keep in 
view, has been, to furnish a book that shall be practically use- 
ful. I have studiously avoided engaging, to any great extent, 
in the discussion of all doubtful matters. These have come 
before me with sufficient frequency. Scarcely had I entered 
upon my labors, before I found myself in the thorny wilder- 
ness of debate, where I was unable to maintain entire silence 
or neutrality. 

The occurrence of blennorrhagia in the male, as resulting 
from leucorrhoea, or from the menstrual fluid, has long been a 
standing theme of controversy, and is still involved in ob- 
scurity. I flatter myself that the manner in which I have dis- 
posed of this subject, will receive the approbation of my 
readers generally. Certain I am, that the views I have ad- 
vanced are in harmony with those maintained by men who 
have had the largest experience, and who have long been on 
the " look-out " for all the facts that are capable of reflecting 
any light upon this interesting question. 

In adducing the cases which are interspersed throughout this 
volume, it has been my aim to select those that appeared to be 
important and valuable from the peculiar symptoms appertain- 
ing to them, as aiding in the diagnosis of different syphilitic 
accidents, or illustrating the principles of a rational and suc- 
cessful treatment. The details of a few of these cases occupy 
an unusual amount of space ; but it is hoped that the instruc- 
tion which they are calculated to convey, will justify the promi- 
nence given them, and repay for the time required in their 
perusal. 

It was a remark of John Hunter, in reference to distinguish- 
ing venereal from other affections, that a true diagnosis is 
the first step in the cure. In one sense, this idea may not be 
strictly logical or correct, that is, so far as relates to the individ- 
ual lesion ; and yet, in a broader signification, the expression is 



PREFACE. vii 

worthy of all acceptation. A medical man may heal a chancre, 
or other syphilitic sore, without having any knowledge or sus- 
picion of its real character. But, in this state of ignorance, he 
will be incompetent to officiate in the premises to the highest 
advantage. He cures the local symptom or difficulty, but not 
the patient. The morbific cause remains unchecked, to work 
further mischief, and, at a future day, to display its effects in the 
appearance of some new symptoms which might never have 
occurred had a true diagnosis been formed of the original 
trouble ; for such a timely discrimination would have suggested 
a constitutional remedial course more appropriate, it is pre- 
sumed, than that which was instituted. Admonished by the 
words of the great medical philosopher above referred to, I 
have embraced every suitable opportunity to dwell, in brief 
and unambiguous language, upon the subject of the diag- 
nosis of the various specific affections or consequences aris- 
ing from impure sexual congress. It is hoped that the 
labor put forth in this direction will be found serviceable 
to the young and inexperienced physician, in his investiga- 
tions of a class of obscure and perplexing cases, that occa- 
sionally present themselves for his decision and management. 
I have endeavored to delineate the characteristic features 
assumed by the various cutaneous affections resulting from 
the venereal poison, and by which the practised eye may gen- 
erally distinguish them from non-specific eruptions. So far 
as. it has been deemed advisable to classify them, and to study 
them in separate divisions, the nomenclature of Professor 
"Wilson has, with little variation, been adopted. This arrange- 
ment will aid in observing and comprehending the laws that 
usually regulate the development of these external manifes- 
tations, and will greatly assist, also, in their diagnosis and 
treatment. The fact that some eruptions have a tendency to 
destroy the anatomical mechanism of the skin, — that is, to 
proceed to ulceration, — while others evince no such disposition, 
has induced that excellent writer, Mr. De Meric, to divide all 
1 



viii PREFACE. 

syphilitic eruptions into two classes ; viz., the ulcerative and the 
non-ulcerative. By this short method of simplification, we get 
rid of sundry hard words employed by dermatologists ; but it 
seems to me that such an arrangement will fail to give to the 
student, or to the medical attendant, a clear and scientific 
knowledge of the respective forms which the syphilodermata 
exhibit, and that, in a practical or clinical point of view, it 
must be attended with no inconsiderable disadvantage. These 
diseases, at any rate, constitute a most important group of 
morbid phenomena, and require to be studied most thoroughly 
by every member of the profession who undertakes their cure. 
Not a few persons on whom they exist, and who apply for 
medical assistance, endeavor to deceive. They have interested 
motives for concealing the truth, and the physician is thrown 
into embarrassing circumstances. If, as a general rule, the 
latter can rely with safety on his own ability to give a true in- 
terpretation of the eruptions, — that is, if he can identify them 
without a knowledge of their antecedents, — he has no occasion 
to hesitate or succumb before the individual under examina- 
tion. His intelligence and sound judgment will soon be appar- 
ent to the other party, who will not only be driven, like the fox, 
from his subterfuges, but will yield respect and confidence to 
the man whom he could not deceive. 

The chapter devoted to the consideration of secondary 
syphilis, where no primary accident has preceded, contains, it 
is believed, a fair presentation of facts, and a truthful express 
sion of the sentiments recognized at the present day by a great 
majority of the most distinguished members of the* profession, 
who have had the most ample opportunities for acquiring 
knowledge upon the particular points concerning which they 
speak. The cases and data upon which their opinions are 
based, will be found to be something more than mere nega- 
tions ; — nor are they brought forward for the vain purpose 
of establishing or demolishing any particular pathological the- 
ory, exclusive of other and higher considerations. It would 



PREFACE. ix 

seem that a candid appreciation of what is embodied in this 
chapter, would lead to the conviction that there is but a very 
narrow margin, or, rather, no ground at all, for controversy 
or doubt ; and yet there are those who discredit the evidence 
thus adduced and fortified. If the reader finds himself still 
roaming in the barren realms of skepticism, let him pause at 
least, and, in an unbiassed and philosophical spirit, listen to 
these facts as admonitory voices to his incredulity ; and let 
him glean therefrom a lesson of wisdom and prudence. This 
will be salutary both to himself and others, even if his mind 
be not fully emancipated from the influence of long-cherished 
opinions of an opposite kind ; for possibly he may be required, 
in the course of his professional life, and in virtue of his 
accredited superior attainments in whatever relates to his call- 
ing, to give his testimony, under the sanctity of an oath, on 
certain points at issue, in the solemn halls of justice, and 
intimately connected with this subject; and involving, among 
other things, the great question of the communicability of 
secondary syphilis. 

No one can boast that he has witnessed and treated all the 
accidents entailed upon the human frame, by the promiscuous 
intercourse of the sexes. Whatever position he may occupy, 
it is scarcely within the range of possibility that his individual 
investigations, experience, and opinions, can be sufficiently 
comprehensive to embrace everything. The recorded observa- 
tions and labors of others should be consulted. Accordingly, 
in gathering materials from which to construct the present 
treatise, I have devoted no little time to the perusal of various 
works on venereal and other specific affections engendered by 
the abuse of the reproductive organs ; and in the statements 
and views which I have offered, I have, in very many instances, 
made other writers participate in the responsibility. Numer- 
ous books, essays, lectures, and monographs have been pub- 
lished, and still have a name to live. Some of them are little 
else than an ingenious and gossamer fabric of conjectures, 



X PREFACE. 

not ^infrequently dressed in a most fascinating style, and 
displaying the workings of a lively imagination. Some of 
them are remarkable for sound erudition ; some are enlivened 
with beautiful rhetorical strokes, and even glitter with the most 
brilliant corruscations of eloquence that can be found in any 
department of literature ; and some are replete with much 
practical good sense. On many topics appertaining to the 
subject of syphilis, a wide discrepancy of opinion character- 
izes the productions of the most gifted authors, even up to the 
present moment, and not a few grave problems still remain to 
be solved. Amid the conflict of sentiment which thus prevails, 
the student in pursuit of reliable information scarcely knows 
how to adjust his mind, or how to sever the true from the 
false — the wheat from the tares. On some of these points I 
have ventured to offer a helping hand, and to interpose a word 
of reconciliation, especially in the field of therapeutics. 

For the most important discoveries that have been brought 
to light since the days of Hunter, in regard to the pathology 
of venereal disorders, — for various and most valuable sug- 
gestions and principles proposed for our guidance in their 
diagnosis, and for most useful rules and improvements in the 
remedial administrations which they require, — the writings and 
other services of Ricord are entitled to preeminent considera- 
tion. But Ricord is not infallible ; and, while rendering this 
willing tribute to his masterly genius, I feel compelled to add a 
slight qualification, and to withhold my assent from a few 
doctrinal views advocated by this distinguished syphilographer. 



CONTENTS 



CHAPTER I. 

PAGB 

Blennorrhagia. — Causes. — Leucorrhoea contagious. — Blennorrhagia not 
necessarily connected with Guilt. — Letter from Dr. Buckingham. — 
Diagnosis of Blennorrhagia. — Symptoms. — Terminates in Gleet. — 
Gleet and Matrimony, 13 

CHAPTER II. 

Treatment of Blennorrhagia in the Male. — Cathartics. — Fomentations. 

— Injections of Nitrate of Silver. — Danger of. — Balsam of Copaiba. 

— Capsules. — Importance of Rest. — Cubebs. — Relapses of Gonor- 
rhoea. — Cases. — Injections in Gonorrhoea. — Painful Erections and 
Chordee. — Lupulin. — Camphor. — Urethral Hemorrhage. — Cases, . 3 1 

CHAPTER III. 

Gleet. — Symptoms. — Case. — Microscopical Appearance of the Dis- 
charge. — Treatment. — Blisters. — Injections. — The Bougie, . ... 60 

CHAPTER IV. 

Balanitis. — Opinions respecting the Prepuce. — Glandulse Odoriferae. — 
Case of Pseudo-Balanitis. — Causes of Balanitis. — Symptoms. — Treat- 
ment. — Phymosis. — Slitting up the Prepuce. — Circumcision. — Par- 
aphymosis. — Treatment, . 72 

CHAPTER V. 

Orchitis produced by Cubebs or Copaiba. — The Epididymis the usual Seat 
of the Disease. — Symptoms. — Treatment. — Puncturing the Testis 
and Epididymis. — Compression of the Testis. — Dr. Fricke, Holmes, 
Coote ? Ricord, and Henry J. Johnson on the Subject, 82 

CHAPTER VI. 

Herpes Prseputialis. — Mistaken for Chancre. — Symptoms. — Cases. — 
Treatment, 96 

(xiii) 



xiv CONTENTS. 



CHAPTER VII. 

Eczema Prseputialis. — Appears in Connection with Chronic Blennorrha- 
gia. — Fraternizes with Impetigo. — Mistaken for a Venereal Disease. 
— Treatment, 103 



CHAPTER VIII. 

In Irritability of the Bladder, the System is rarely disturbed. — In In- 
flammation of the Bladder, it is. — Difference of Symptoms in Irritable 
Bladder and Calculus. — Treatment of Irritable Bladder, 108 



CHAPTER IX. 

Excoriations. — Most frequent Locality. — Generally but one excoriated 
Patch. — Complaint apt to return, 113 



CHAPTER X. 

Urethral Pains. — The Testicles sometimes participate. — Also the Blad- 
der. — Depressing Influence on the Mind. — Treatment, 118 



CHAPTER XI. 

Spermatorrhoea, — Causes. — Pathology. — Treatment. — Mental Disci- 
pline. — Lupulin. — Note from Dr James Jackson. — Porte Caustique. 
— Anodyne Injections. — Bromide of Potassium. — Marriage. — Cas- 
tration, 121 



CHAPTER XII. 

Gonorrhoeal Ophthalmia. — Disease not mentioned by John Hunter. — 
Inoculation the most frequent Cause. — Opinions of Cooper and Others. 
— Letter from Dr. Henry W. Williams, with Cases. — Diagnosis. — 
Treatment, 140 



CHAPTER XIII. 

Ophthalmia Neonatorum. — Most frequent Cause of the Disease. — Symp- 
toms. — Treatment, 152 



CHAPTER XIV. 

Gonorrhoeal Rheumatism. — Specific Cause unknown. — Structures in- 
volved. — Sir A. Cooper's first Case. — The Disease described by Mr. 
Brodie. — Dr. Johnson's Opinion. — Diagnosis. — Treatment,. . . . 156 



CONTENTS. xv 



CHAPTER XV. 

Vegetations. — Are not venereal. — Are known by sundry Names. — 
Their Situation. — Their anatomical Structure. — Treatment. — Papil- 
lomata, 162 

CHAPTER XVI. 

Blennorrhagia in the Female. — The Speculum. — Diagnosis of Blennor- 
rhagia in the Female. — Blennorrhagia in very young female Children. — 
Varieties. — Chronic Vaginitis. — Uterine Blennorrhagia. — Treatment. 

— Urethral Blennorrhagia in the Female, 168 

* 

CHAPTER XVn. 

Syphilis. — But one Syphilitic Virus. — Its intrinsic Nature unknown. — 
Indurated Chancre of rare Occurrence. — Generally solitary. — Indura- 
tion deceptive. — Interval between Exposure and morbid Phenomena. 

— Abortive Treatment of Chancre, 187 

CHAPTER XVIII. 

Constitutional Treatment of Chancre. — Principles of Health to be en- 
forced. — Analyses of the Blood by M. Grassi. — Influence of Iodide 
of Potassium on the Blood. — Artificial Syphilization. — Methods of 
treating the Venereal Disease, 199 

CHAPTER XIX. 

Chancre. — Indurated Chancre. — According to Ricord, can alone im- 
pregnate the System. — This Theory not sustained by Facts. — Indu- 
rated Chancre rarely followed by suppurating Bubo. — Mercury the 
best Agent for curing indurated Chancre. — Local Applications. — 
Swelled Tongue. — Ulcers on under Surface, 216 

CHAPTER XX. 

Masked Chancre. — Definition. — Usual Seat. — Chancre and Gonor- 
rhoea from the same impure Connection. — Chancre upon the Vagina and 
upon the Os Uteri, 23$ 

CHAPTER XXI. 

Inflammatory Chancre. — Induced by improper Treatment. — Patients of 
irregular Habits liable to it. — Treatment, 23* 

CHAPTER XXII. 

Phagedenic Chancre. — Difference between Phagedama and Gangrene. 

— Treatment. — Potassio-Tartrate of Iron. — Carbonate of Ammo- 
nia.— " Swan Alley Sore" of Prostitutes, 240 



xv i CONTENTS. 



CHAPTER XXIII. 

Bubo. — " Bubon D'Emblee." — Bubo occurs in the same side with the 
Chancre. — That from indurated Chancre rarely suppurates. — True 
Venerea] Bubo indolent. — Treatment. — Sloughing Bubo, .... 254 

CHAPTER XXIV. 

Secondary Syphilis. — Period of Latency. — Longest time between pri- 
mary and secondary Lesions. — Shortest time. — Difficulty and impor- 
tance of a correct Diagnosis, 266 

CHAPTER XXV. 

Syphilodermata. — The Action of the Venereal Poison slow. — Is in the 
Blood. — Diagnosis of Venereal Eruptions. — Anaesthesia or deficient 
Sensibility of the Skin. — Cicatrices, 273 

CHAPTER XXVI. 

Secondary Symptoms without primary. — Cases. — Contagion of the 
Blood. — Transmission of the Venereal Virus from the Nurse to the In- 
fant, and vice versa. — M. Trousseau. — Communicability of secondary 
Syphilis, 281 

CHAPTER XXVII. 

Syphiloderma Erythematosum or Roseola Syphilitica. — Is the simplest 
form of cutaneous Eruptions. — Eruptions produced by Balsam Copaiba 
and Cubebs. — Diagnosis. — Is occasionally confounded with Measles. 

— Treatment, 306 

CHAPTER XXVIII. 

Lichen. — Diagnosis. — Passes into Tubercles. — Associated with Tuber- 
cles, Squama?, and Pustules — also with Iritis. — Treatment, .... 310 

CHAPTER XXIX. 

Squamous Syphilitic Eruptions. — Are met with in young Subjects. — 
Their most prominent Features. — Errors in Diagnosis in Consequence 
f the Absence of the Copper Color. — Case. — The Squamae belong 
either to Psoriasis or Lepra. — Treatment, 325 

CHAPTER XXX. 

Tubercular Syphilitic Eruptions. — Present various Appearances. — Some- 
times ulcerate. — Sometimes disappear by Absorption. — Phagedaenic 
Ulcers, and Serpiginous Ulcers. — Perforating or Syphilitic Tubercles. 

— Treatment of tubercular Eruptions — of ulcerated Surfaces. — 
Mucous Tubercles, 342 



CONTENTS. xvii 

CHAPTER XXXI. 

Syphilitic Pustules. — Do not yield pure Pus. — Divided into two Groups 
by Willan. — Of Rupia, two Varieties. — Treatment of Pustular Syph- 
ilis, 355 

CHAPTER XXXII. 
Alopecia or Baldness, 366 

CHAPTER XXXIII. 

Ulcers of the Tongue. — Fissures or Cracks. — Treatment. — Sloughing 
Ulcerations of the Throat. — Local Treatment. — Nitric Acid. — Com- 
pound Tincture of Benzoin. — Constitutional Remedies, 370 

CHAPTER XXXIV. 

Syphilitic Diseases of the Nostrils and Nasal Fossae. — May be secondary 
or tertiary, superficial or profound. — Insidious in their Approach. — 
Treatment, 386 

CHAPTER XXXV. 

Syphilitic Iritis. — Sometimes a secondary, sometimes a tertiary Affection. 

— Symptoms. — Diagnosis. — Treatment. — Mercury. — Mr. Carmi- 
chael's Substitute. — Dr. H. W. Williams's Plan of Treatment, . . .391 

CHAPTER XXXVI. 

Tertiary Syphilis. — Organs and Tissues involved. — Syphilis and Scrofula. 
Ricord, Lugol, and Phillips. — Tubercula Gummata. — Rarely met 
with. — Diagnosis. — Cases. — Syphilitic Gummata in the Muscles — 
Lungs — Liver — Brain — Bones, etc. — Treatment. — Iodide of Po- 
tassium, 401 

CHAPTER XXXVII. 

Syphilitic Sarcocele, or Orchitis. — Belongs to no particular Period of 
Syphilis. — Commences in the Tunica Albuginea. — Suppy, ition rarely 
takes place in the Testicle. — Atrophy of the Gland. — iXhe Disease 
apt to recur. — Diagnosis. — Treatment, 416 

CHAPTER XXXVIII. 

Diseases of the Periosteum and Bones. — Syphilitic Osteocopes. — Nodes. 

— Cranial Exostoses. — Tumors on the Dura Mater. — Cases of Intra- 
cranial Affections related by Mr. Todd of London — by Dr. Reid of 



xviii CONTENTS. 

Ireland. — Case related by Mr. Reeve. — Case in the Author's Practice. 
Case at Rainsford Island Hospital. — Diagnosis. — Treatment of Ter- 
tiary Pains — of Nodes. — Mercury. — Local Treatment, 421 

CHAPTER XXXIX. 

INFANTILE SYPHILIS. 

Not always secondary. — Procreating Element the Medium of contaminat- 
ing the Foetus. — Blight of Ovum and Abortion. — The Circulation the 
most common Mode of infecting the Foetus. — Infection rarely commu- 
nicated to the Child by the parturient Mother. — The milk of a Syphi- 
litic Nurse poisonous. — An Infant born with Syphilis cannot infect its 
Mother, but may a strange Wet-nurse, etc., 432 



GONORRHOEA AND SYPHILIS, 



CHAPTER I. 

BLENNORRHAGIA. 

For a very long period, the identity of syphilis and gonor- 
rhoea was a fruitful theme of debate; and opinions the most 
contradictory were entertained by the authors and schools thus 
engaged in controversy. But the times have changed ; and the 
dawn of a new and better epoch now opens upon the path of 
the medical practitioner. By the talents, and the patient and 
well-directed labors of some of the most eminent writers that 
have come upon the stage during the last quarter of a century, 
the laws that govern the two diseases we are about to consider, 
have been brought from their long night of obscurity to the 
light of day, and are now comparatively well understood. And 
while it is a matter of congratulation that many of the theories 
which once flourished, and held a portion of the medical world 
spell-bound in error, have fallen asleep with the renowned per- 
sonages who promulgated them, there is equal occasion to 
rejoice that the field of therapeutics has at last been explored 
with a large amount of success, and its various products, which 
were once used without method, without reason, and without 
mercy, are in more competent hands, and are made subservient 
to a more rational and satisfactory treatment of the maladies in 
question. 

At the present day, the more enlightened members of the 
profession agree in the opinion that gonorrhoea is not a vene- 
real affection ; and yet as gonorrhoea is usually contracted 
under circumstances identical with those that give rise to 
syphilis, a treatise on the latter disease, however judiciously 

2 (13) 



14 GONORRHOEA AND SYPHILIS. 

prepared, would be regarded as deficient in design, unless the 
former complaint received a due share of consideration. 

Gonorrhoea, blennorrhagia, clap, and urethritis, are used as 
synonymous terms, and are employed somewhat indiscrimi- 
nately to denote inflammation of the mucous membrane of 
the urethra and other portions of the geni to-urinary passages, 
attended with infectious, muco-purulent discharge, and a scald- 
ing pain in micturition, consequent upon impure sexual con- 
gress. The discharge is not uniform in its physical charac- 
ter or composition. At first, it may consist almost entirely 
of mucus ; in a few hours the mucus will contain pus-globules, 
which increase in relative proportion, until the disease reaches 
its climax. As soon as it begins to wane, and to pass into its 
ultimate stage, the morbid secretion is again changed, and is 
once more characterized by a preponderance of mucus, until 
at last it becomes nearly transparent ; — thus indicating that 
the pus-globules, upon which its contagious properties are 
supposed to depend, have ceased to be formed. This abnor- 
mal discharge is the blennorrhoea luodes of Dr. Good, the 
gonorrhoea impura of Cullen, the venereal catarrh of Capuron, 
the catarrhal primary syphilis of Wallace, the chaude-pisse, as 
it is called in the vernacular and graphic parlance of the 
French populace. Still other names might be cited as applied 
to inflammation of the male and female organs of generation, 
accompanied with muco-purulent secretion, having a charac- 
ter totally different from the specific virus of true syphilis, 
although received in the same manner and by the same or- 
gans ; — its medium of reception being cohabitation with an 
infected individual. No generic term, however, which has 
reference to the complaint, is free from objections ; and, until 
some better phraseology is introduced and acknowledged in 
this department of nosology, we must be content to avail our- 
selves of technical expressions that are sufficiently under- 
stood, and that have so long and so well answered all practical 
purposes. 

Causes. — Simple urethral running, or blennorrhagia sim- 
plex^ in the male, consists in an increased secretion from the 
urethral glands or follicles, and proceeds from mere local irri- ' 
tation, — is destitute of any contagious element or virulence 



BLENNORRHAGIA. 15 

of any kind, and may be produced by a variety of causes. 
Of these causes, one of the most frequent in the opinion of 
some writers, is, sexual intercourse with a female who is labor- 
ing under^leucorrhoea, or some other morbid condition of the 
vulva, vagina, or uterus, which may furnish a catarrhal dis- 
charge possessing more or less acrid properties, but specifically 
different in its nature from the malignant gonorrhoea impura 
just mentioned, and which alone can be propagated. Men have -* 
also been known to receive a blennorrhagia from healthy women 
with whom they have had sexual intercourse while the men- 
strual flux has been upon them. The vaginal secretions, just 
previous to menstruation, will likewise occasion urethral irrita-^ 
tion in men of peculiar susceptibilities. In women, blennor- 
rhagia is a complaint rarely met with, compared with the fre- 
quency with which it falls to the lot of men. Ricord states, 
with characteristic brevity, that women give twenty claps for ' 

>one which they receive. Particular articles of food, such as 
salted meats, cayenne pepper, ginger, etc., have the reputation 
of causing mild blennorrhagia. Some persons cannot eat aspar- 
agus without having a gonorrhoeal discharge from the urethra, a 
few hours afterwards. Spirituous liquors, beer, and coffee, have 
been accused of producing the same effects ; so, also, the use of 
cantharides, injections, bougies, and pessaries, will give rise to 
a morbid secretion closely resembling ordinary gonorrhoea. 
The same results occasionally supervene upon violent and long- 
continued dancing, frequent venereal indulgence, and the want 

x of co-aptation in the genital organs of the two parties. Mas- 
turbation, rheumatism, and gout will likewise occasion gonor- 
rhoea. Druitt mentions a case of most obstinate local irrita- 
tion, attended with • urethral discharge, brought on by riding 
several miles on horseback, without a saddle. The patient was 
a married man, and had a tendency to irritation of the mucous 
membranes. During treatment he suffered a severe attack of 
rheumatism. Dr. Blackmail relates the case of a patient sev- 
enty years old, who was subject to gout, and, during one of his 
attacks, was seized with a most copious blennorrhagic discharge 
from the urethra. Dr. B. is positive that this discharge was 
induced by gout. Dr. Watson, of New York city, has seen two 
cases of the same kind. Labor and abortion are to be reck- 
oned among the causes that give rise to blennorrhagia. Leu- 



16 GONORRHOEA AND SYPHILIS. 

corrhoeal discharges in the female are supposed to be capable 
of generating in the male an assemblage of phenomena almost 
precisely like those developed in ordinary gonorrhoea derived 
from impure connection. With reference to the contagious 
nature of leucorrhoeal matter, Whitehead says, "If ques- 
tioned on the subject, I should have no hesitation to return an 
answer in the affirmative, in all cases where the discharge in 
the female exhibits decidedly purulent properties, having my- 
self witnessed several incontestible instances of the kind." 

Hitherto no success has attended any experiments or exam- 
inations that have been made with a view to detect the charac- 
teristic differences between a true gonorrhoea and some other 
discharges from the genital apparatus of the female, and which, 
it is said, occasionally excite a mild gonorrhoea in the male. 

The medical practitioner is sometimes called upon to give his 
opinion on the question of suspicion, and to adjust difficulties 
which spring up within the domestic circle in connection with 
this embarrassing subject. As the conscientious interpreter of 
events, he can feel justified in expressing a conviction that blen- 
norrhagia does not always have its origin in a specific virus, nor 
absolutely imply moral delinquency on the part of any one ; 
for the accident may take place under the most varied circum- 
stances, and from a multiplicity of causes, as detailed above. 
The bare fact that a man or woman has the complaint, does not 
Necessarily carry with it demonstrative proof of guilt. The dis- 
ease may happen to the most virtuous and pure individual, 
male or female. If the surgeon can obtain access to all the 
antecedents in the premises, without concealment from any 
quarter, he will have no difficulty in arriving at a true diagno- 
sis. A great and not infrequent obstacle which the medical 
attendant is compelled to meet, in endeavoring to form a cor- 
rect opinion, is this: he must judge in part from the general 
character of the patient ; and yet the general character for 
truthfulness, in matters affecting disease of the genital organs, 
cannot be depended upon. Many persons, who are perfectly 
reliable on all other occasions, will not hesitate to deceive their 
medical advisers concerning impure connections, even when 
they know that deception, in any degree, will operate against 
their interests, perhaps for life. 

Were it possible to collect all the reputed sporadic cases of 



BLENNORRHAGIA. 17 

simple blennorrhagia that occur in any one of our large cities 
during the average professional lifetime of the physician, the 
number of such instances, reckoned in the abstract, might seem 
considerable ; and the sensualist might essay to appropriate the 
fact to his personal advantage, in the hope that it might shield 
him from the multitude of his sins, however frequently he had 
gone astray into the path of licentiousness. But if the history 
of every blennorrhagia could be brought to light, I believe it 
would appear that for every instance not coupled with a depar- 
ture from rectitude, hundreds would be found to originate 
under directly opposite circumstances. So that while the med- 
ical man admits that various innocent causes may induce gon- 
orrheal discharges, I think he may feel warranted in the 
opinion that the combined agency of all these sources is quite 
insignificant, compared with the agency attributable to the one 
chief cause, namely, cohabitation with an individual affected 
with a specific and contagious blennorrhagia ; a disease of the 
genito-urinary organs, arising from an animal poison generated 
by impure sexual intercourse, and easily confounded with vari- 
ous non-specific, non-contagious, inflammatory affections, which 
occasionally attack the same organs, and are likewise character- 
ized by secretions more or less puriform. But these discharges 
are minus the true, infectious, gonorrhoeal element. In cases, 
however, where there is ground for reasonable doubt as to the 
cause of blennorrhagia, it is right that the suspected party 
should have the benefit of that doubt. The medical witness 
will be justified in leaning somewhat to the side of mercy. 

I have corresponded, and otherwise conferred, with many 
medical gentlemen, with a view to obtain their opinion with 
regard to simple leucorrhcea as a cause of contagious gonor- 
rhoea. Those who have been long in practice, and who have 
had large experience in the treatment of both diseases, consider 
it a libel on the female sex to attribute the latter disorder to 
the former. One distinguished surgeon, who has probably 
seen as many cases of urethritis as any man in the country, 
informs me that he never saw an instance which he thought 
was occasioned by leucorrhcea. Were this disease capable of 
giving rise to a veritable gonorrhoea, few married men in the 
wide universe would escape being poisoned with it by their 
wives, for it is well known that leucorrhceal discharges afflict, 
2* 



18 GONORRHOEA AND SYPHILIS. 

more or less, a majority of adult females. I feel bound, per 
contra, to cite the opinion of a junior correspondent, whose 
scientific acquirements I greatly respect, and who occupies a 
favorable post of observation in the chief city of our union. 
He writes : " In reply to your note asking me to give you my 
views, derived from personal observation, as to the possibility 
of a woman affected with simple leucorrhoea, or during her 
menstrual period, communicating a gonorrhoea to the male, 
I would state that I have no doubt, whatever, as to the possi- 
bility of such communication ; and I would go even further, 
and ' assert that a vast majority of cases of gonorrhoea in the 
male, arise in this manner from intercourse with women who 
have not the disease themselves." During a practice now of 
thirty years, I have had scores of patients, who have pretended 
that their urethritis might have been derived, or probably was 
derived, from the vaginal or uterine secretion now alluded to ; 
but I have never seen any evidence that convinced me of the 
fact. My faith in the power of leucorrhceal secretion as a 
source of blennorrhagia in the male, is scarcely equal to a 
grain of mustard seed ; and I usually turn a deaf ear to all 
such specious explanations. I am unable to recognize this 
antecedent as the procuring cause of such an event. The sub- 
ject, however, is one of which no man has the key of absolute 
knowledge. It must, from the very nature of things, always 
remain a matter of opinion. My own coincides with that of 
Sigmund — that gonorrhoea alone produces gonorrhoea.* 

I will here introduce an instance of mild urethritis, the 
cause of which is not difficult of explanation ; but which, had 
it concerned parties less intelligent in medical matters, might 
have given occasion for dark suspicions and recriminations. 

A few years since, an intimate medical friend of mine, of un- 
impeachable character, had an attack of simple blennorrhagia, 
or pseudo-gonorrhoea. The facts in the case, as related by 
himself, were these : He had never indulged in illicit inter- 

* In conversation a few months since, with a member of the profession, 
who has been President of the American Medical Association, he remarked 
that he had long been " on the watch " for a case of gonorrhoea produced by 
leucorrhoea or by the menstrual discharge, but had never met with one. No 
man in this country ever enjoyed a more extensive range of observation than 
the one here referred to. 



BLENNORRHAGIA. 19 

course, and his wife was above suspicion. He had had no 
sexual communication with her for about three months, as she 
was nursing a young infant. One morning, after having con- 
nection with her the previous night, he experienced severe 
irritation and smarting on passing urine, followed immediately 
by sharp pain, which lasted a few moments, and then subsided 
until the next period of micturition. During the interval, 
however, there was a constant sensation of uneasiness in the 
urethra. On the first day of the attack, the glans penis became 
swollen, and there was a moderate discharge of glairy mucus, 
of the consistence and appearance of the white of egg. On 
the following day, the glans and preputial surfaces were ex- 
coriated and decidedly sore. This state of things continued 
for four days, when the irritation and swelling abated, and the 
urethral discharge assumed a more purulent character, being 
thick, pasty, and of a light yellow tint. As the hypersecre- 
tion acquired the latter properties, it lessened in quantity, and 
at the same time the irritation and smarting nearly ceased. 
At the expiration of ten days, the blennorrhagia and its com- 
plications disappeared. Rest and cleanliness were the reme- 
dies. The above phenomena did not disturb the harmony or 
mutual regard and confidence of the parties, who were not only 
persons of high social position, but of the best intellectual and 
moral culture. The fact that the symptoms came on so shortly 
after indulgence, and also that they subsided without medi- 
cine, sufficiently separates them from blennorrhagia derived 
from a contagious virus, which usually requires an incubation 
of several days before its specific action is developed. The 
fault was not in the woman. She had no vaginal trouble. 
The accident was due to the peculiar susceptibility of the 
other party. Such results, and even worse ones, at least so 
far as regards the prepuce and glans, are not very uncommon 
in newly-married men. A few years since, Dr. W. W. Mor- 
land, of this city, requested me to see a patient of his, who 
had a phagedgenic ulcer on the prepuce. The patient was 
twenty-five years old, and had been married one week. In a 
day or two after his nuptials, the prepuce became enormously 
swollen and oedematous. The young man bore a good char- 
acter, and the bride was also without reproach. He sent for a 
physician, who, after an examination of the parts, announced 



20 GONORRHOEA AND LYPHILIS. 

to the patient, in a coarse, rude manner, " that he had got the 
pox," and prescribed accordingly. The young husband was 
greatly enraged, dismissed the physician instanter, and sent for 
Dr. Morland, who decided that the lesion was not specific. All 
the circumstances connected with the case and with the young 
couple abundantly proved the correctness of Dr. Morland's 
diagnosis. The phagedenic action, in this instance, set in 
with great suddenness, was very rapid in its progress, and did 
considerable mischief before it was arrested. 

Urethritis and ulcerations sometimes occur under circum- 
stances so obscure, that the medical attendant cannot arrive at 
any satisfactory conclusions as to the cause of the affection. 
In this connection, I submit the following communication re- 
lating to two cases reported by Dr. C. E. Buckingham, recently 
physician to the House of Industry, South Boston : — 

" Cases have presented themselves of mucous discharges, and 
of ulceration, in which I do not in the least degree doubt that 
impure connection was never had. They have not been nu- 
merous. But suppose that one of your own personal friends, 
who acknowledges that in former years he has had gonorrhoea, 
comes to you. He has not married. He confesses that within 
four or five years he has had frequent sexual intercourse; but 
says that for the last eight weeks he has not touched a 
female, and that within forty-eight hours there has been itching 
and redness about the meatus urinarius. On examination, 
you find there is moisture, but nothing which you can decide 
at once to be purulent. He is cleanly in his person and dress. 
Now, can you with any consistency doubt the statement of 
such a person, who could not have the reason of shame to 
prevent a knowledge of what you knew before ? In April 
last (1856), such a case was under my care, and was treated 
at* the beginning, simply with an astringent wash to the part. 
In two or three days there was a profuse muco-purulent dis- 
charge from the meatus, into which no syringe or other instru- 
ment had been introduced till that time. The disease did 
not terminate till after the middle of September. It is true, 
that for days at a time — not more than three — there would 
be entire cessation of the discharge, and it would then re- 
commence. In this time there was once painful swelling of 



BLENNORRHAGIA. 21 

the testicle, which yielded easily. I have seen this patient 
to-day (November 7, 1856), upon other business, and he in- 
forms me that since the date mentioned, he had no returns 
of his trouble. 

" My experience with syphilitic cases while in attendance upon 
the Hospital at South Boston, was not so great as you probably 
imagine. 

" I cannot forbear mentioning one case under my private treat- 
ment, which gave me great annoyance, and which you may be 
able to explain. Several years since, a friend, himself a physi- 
cian, unmarried, called- upon me for advice concerning what, upon 
any other person, I should have called an indurated chancre, sit- 
uated upon one side of the prepuce and quite near the frgenum. 
He denied ever having had sexual intercourse at all. He had 
been treating it for several days with mild astringent lotions, but 
it constantly increased and had become as large as my forefinger 
nail. He was fully capable of detecting chancre in any one 
else, and as capable of treating it ; but he called upon me be- 
cause he could not make out what this was, and with the fullest 
belief that I should ridicule his statement. He acknowledged 
the wearing of a pair of riding-trowsers a week or two previous, 
borrowed from a friend for an afternoon's ride. He had no rea- 
son, he said, to think his friend had the disease, or if he had, 
that he would have loaned him the clothing unless it were known 
to be clean. I laughed at his account, and proposed inocula- 
tion, which he assented to ; and his thigh was inoculated by 
myself with the discharge from the ulcer, and I believe in more 
than one spot. The apparent chancre was thoroughly cauter- 
ized with nitrate of silver, which did not put a stop to its spread- 
ing. The prepuce became very cedematous, and the inoculation 
had no effect. As the sore continued to extend, at his own re- 
quest, he was put upon mercurial treatment, was etherized, 
and the part touched with nitric acid. After the separation of 
the slough formed by the acid, the oedema became so great that 
it was impossible to uncover the glans ; but the sore did not 
diminish in size. The mercurial was continued for many days 
without any perceptible effect upon the gums. Several weeks 
after the discontinuance of medicine, the sore began to heal, and 
so far as I know, he has never had any symptoms of venereal 
affection. I am frequently in the habit of seeing this gentleman, 



22 GONORRHOEA AND SYPHILIS. 

and am quite certain that he is in perfectly good health. I know 
also that while he was under treatment he became a married 
man, and am quite certain that his wife is a healthy woman. 
This is a case for speculation. 

" I am, very respectfully, yours, 

" Charles E. Buckingham." 

In regard to the first case furnished by Dr. .Buckingham, the 
query arises whether the suspicious connection, which is acknowl- 
edged to have taken place eight weeks anterior to the blennor- 
rhagia, is to be regarded as the occasion of the urethral difficul- 
ty. Instances are on record showing that more than two months 
may pass away before the gonorrhoeal infection manifests itself. 
Br. Samuel Morrill, of this city, once had a case quite similar 
to the one above related by Dr. B. Dr. Morrill's patient had 
intercourse with a prostitute in Buenos Ayres, and the next day 
sailed for Boston. The ship had a long passage. In just sixty 
days from the time he visited this woman, and while he was yet 
at sea, the man was seized with a violent blennorrhagia, for which 
he consulted Dr. Morrill as soon as he reached port. 

Hunter believed that the -period between exposure and the ap- 
pearance of purulent urethral discharge, ranged all the way 
from a few hours to several weeks. His opinion was based upon 
statements and examples furnished by his own patients. His 
theory was, that the inflammatory action in some constitutions 
might exist for a long time before the suppurative period. 

The second case related by Dr. Buckingham is a legitimate 
one for " speculation." By inappropriate treatment, patients 
often convert a harmless pimple, or an eczematous or herpetic 
vesicle situated on the glans or prepuce, into an ugly, chan- 
crous-looking sore. Nothing is easier than to manufacture 
such a sore. I have seen not a few created in this manner. 
In the case under review, Dr. B. had no opportunity to see the 
lesion " in a state of nature ; " and the speculative idea that 
suggests itself to my mind in relation to it, is, that its normal 
features had been modified by the applications resorted to, 
before it came under his inspection. Its final history would 
seem to prove that it possessed no specific attribute. I once 
had a case not unlike this. The patient was a pale, thin, 
feeble-bodied man, forty years of age, and suffered extremely 



BLENNORRHAGIA. 23 

from dyspepsia. When he called upon me, he had a sore on 
the glans as large as a half-dime. It commenced as a mere 
pimple. The patient had tried his own skill «at it, and nitrate 
of silver had frequently been applied. The sore was quite 
deep. It was not painful, and yielded a very scanty discharge. 
The man had a nice woman for a wife, and was himself of 
good character. He ignored all illicit intimacy with the* other 
sex, and I did not hesitate to accept his statement. Although 
the ulcer bore a strong resemblance to chancre, I did not 
think it entitled to that epithet. The patient was put upon 
tonic treatment as far as his system would tolerate ; and nitric 
acid, — two drops to the ounce of water, — aromatic wine, 
tannin, and weak chlorinated water, formed the local applica- 
tions. Four months elapsed before he was rid of the sore. 
He had no bubo nor secondary accidents. 

Contagious blennorrhagia, — that is, a blennorrhagia that 
can be communicated, — is a specific disease. It cannot give 
rise to secondary syphilitic accidents. In all cases, where 
such phenomena have followed a gonorrhoea of the urethra, it 
is certain that true chancres, — such as are termed by French 
writers chancres larves, — must have coexisted. M. Baumes, of 
Lyons, states that simple blennorrhagia, without the existence 
of chancre in the urethral canal, may be followed by constitu- 
tional manifestations, such as well-marked, rounded ulcers on 
the tonsils, mucous tubercles at the commissures of the lips, 
about the arms, on the scrotum, — syphilitic ecthyma, papular 
eruptions, etc. This opinion is not sustained by the history 
of the disease. There is no well-authenticated example, 
which proves that an individual, in whom the mucous surfaces 
have been examined during an attack of blennorrhagia, with- 
out the existence of chancre, has ever afterwards had second- 
ary syphilitic lesions in any form. One of the best arguments 
and proofs that can be offered against the identity of the 
syphilitic virus and the virus of gonorrhoea, is, that the con- 
stant tendency of the first is to produce secondary symptoms, 
which we denominate constitutional syphilis ; while it is 
equally true that gonorrhoea, however severe, or however 
protracted in duration, is never followed by such symptoms. 
In the treatment of gonorrhoea, an erythematous efflorescence 
of the skin, induced by the free exhibition of cubebs or 



24 GONORRHOEA AND SYPHILIS. 

balsam of copaiba, is occasionally met with ; and if these reme- 
dies are continued after the appearance of the preternatural 
cutaneous redness, a well-marked, lichenoid eruption, accom- 
panied with much itching, is very liable to break out on the 
trunk of the body and upper portion of the extremities. But 
this eruption has no pathological relations to gonorrhoea. It 
subsides in six or eight days after the discontinuance of the 
medicines that gave rise to it. It is perfectly harmless, and 
does not in any wise merit a place among syphilitic papules. 

Certain consequences and sequelae follow blennorrhagia, 
but they are not venereal. Gonorrheal ophthalmia and gonor- 
rheal rheumatism are constantly met with ; so also swelled 
testicle, sometimes called blennorrhagic epididymitis, occurs 
somewhat frequently as an accompaniment or consequence of 
gonbrrhoeal discharge. The inguinal glands now and then 
become engorged and even suppurate, while a man has gonor- 
rhoea upon him. This condition of the glands is to be regarded 
in the light of a sympathetic affection, — as a bubo, an 
adenitis, which is no more to be considered a venereal symp- 
tom than an engorgement of the axillary ganglia, which may 
take place while a felon is forming on the finger or a vaccine 
pustule on the arm. 

Diagnosis. — Candidates for medical treatment occasionally 
imagine that they achieve a great exploit, if by an ingenious 
fabrication of stories, they succeed in deceiving the physician 
in regard to the origin of their blennorrhagia. The physician, 
on the other hand, has no positive means of distinguishing, in 
all cases, a simple gonorrhoea, not brought on by impure 
sexual intercourse, from a specific urethritis caught from an 
infected prostitute. Although in some rare instances of non- 
specific urethritis, the symptoms assume great severity, yet it 
may be laid down as a general rule, that they are characterized 
by comparative mildness. The inflammation is moderate, — 
producing but little pain or scalding in micturition ; the ure- 
thral secretion occasions little or no excoriation of the parts 
with which it comes in contact, and the complaint yields to 
gentle treatment. 

As an instance of the devices resorted to by patients for 
purposes of deception, let me present the following; — 



BLENNORRHAGIA. 25 

Case. — A married man who was of good standing in his 
neighborhood, called upon me one day for the cure of a 
recent blennorrhagia. His wife was a woman of irreproach- 
able habits, and was in good health. The husband denied all 
improper behavior, and knew no more than " a dead man " 
how he could have contracted his disease. I told him that as 
far as treatment was concerned, it was no matter, — and pre- 
scribed copaiba capsules. At his second visit he stated that 
he had ascertained the source of his gonorrhoea. One even- 
ing, just previous to the commencement of his urethral run- 
ning, he attended a ball, at which he wore a pair of trowsers, 
borrowed of a friend who had the clap. My patient got rid 
of his gonorrhoea in about three weeks. Scarcely had a 
twelvemonth elapsed, before he presented himself for the 
treatment of secondary syphilis. Tubercles and pustules 
were scattered upon the face ; — the arms and legs were the 
seat of numerous pustular blotches and ulcers ; — the buccal 
cavity also showed several well-marked syphilitic sores. The 
man now acknowledged that he had long been intimate with 
lewd females, — that he had suffered from primary syphilis 
before he consulted me, — and that the exigency of the cir- 
cumstances he was in, induced him to withhold the truth in 
regard to the symptoms, for which he first consulted me. 

After all that can be said, the physician must form his diag- 
nosis, in very many cases, from extraneous circumstantial evi- 
dence added to that derived from the symptoms themselves. 
Syphilographers tell us that if a discharge come on only a few 
hours after connection, and if it have continued several days 
without inflammatory symptoms, — if the patient have been 
subject to some discharge, after an excess of venery or of wine, 
— in all such cases it is probable that he labors under some 
other form of urethral disease, and that although the inter- 
course of the sexes may have been the exciting cause, still there 
may be no imputation on the purity or cleanliness of the female. 
The hypothesis founded on all these circumstarnces may be 
safe in some cases, in others not. In November, 1856, a young 
man consulted me for a blennorrhagia, which appeared within 
forty-eight hours after he had connection with a woman of the 
town. The discharge had existed four days, and was very 
copious. The other symptoms, usually attendant on urethritis, 
3* 



26 GONORRHOEA AND SYPHILIS. 

were very mild. The patient stated that he had frequently 
been troubled with the same complaint, but that it had never 
set in so soon after exposure as on this occasion. He led a 
sedentary but dissolute life. The disease degenerated into a 
gleet, which lasted six months, and was finally cured by the 
application of cantharidal collodion to the penis. That this 
was an instance of specific gonorrhoea, arising from impure 
connection, I do not doubt. I have occasionally met with sim- 
ilar instances. Where the urethra has suffered from repeated 
attacks, and where the patient is a hard drinker, as was this 
young man, the phenomena of the complaint do not appear 
with the same regularity as to time or character, as in a first 
blennorrhagia, and in an individual not addicted to excessive 
libations. 

The average interval between exposure and the occurrence 
of the blennorrhagic secretion is from four to five days. This 
fact may help to form a tangible basis, on which to construct 
a differential diagnosis. All deviations from the time here speci- 
fied are to be considered as exceptional cases, dependent on 
peculiar circumstances. 

Symptoms. — In relating the history of symptoms, patients 
generally state, that within twenty-four hours after suspicious 
coitus, they begin to notice strange sensations along the ure- 
thral canal, such as increased heat, irritation, itching, etc. 

There is scarcely any period of incubation or absolute dor- 
mancy. The virus commences its action almost from the mo- 
ment it is deposited. The disease, at first, consists of a little 
discharge from the lips of the meatus urinarius, which are 
glazed over, or perhaps become patulous, red, and slightly 
tumefied. On squeezing the organ, the morbid exudation slides 
along the canal, and runs down upon the fraenum in thick, 
transparent, ropy masses. These symptoms constitute the ini- 
tial stage of blennorrhagia. By the second or third day from 
the first appearance of the mucous secretion, the inflammation 
acquires more intensity. The discharge becomes more abun- 
dant, and instead of being merely a glutinous substance, it 
is changed to purulent matter — is more consistent — of a 
greenish-yellow tinge, and emits a disagreeable, nauseous odor, 
wholly different from that of ordinary pus. The effluvium is 



BLENNORRHAGIA. 27 

sometimes so strong and impressive on the olfactories, that the 
practitioner recognizes the nature of the case before the patient 
tells what ails him. This disgusting symptom, when once 
noticed, will ever afterwards be remembered, and needs no 
further description. By the time the secretion becomes puri- 
form, the patient begins to complain of ardor urinse, and has 
frequent calls to urinate. The inflammation diminishes the 
normal calibre of the urethral canal, and consequently the 
stream of urine is small and flattened. The shaft of the penis 
is enlarged, and the gians assumes a dark-red color, is tender to 
the touch, and very likely excoriated. If the inflammation be 
limited to the fossa navicularis, as it usually is for several days, 
the pain in micturition will also be confined to this spot. If the 
organ be pressed between the thumb and finger, the patient 
will complain of being hurt at this part, and the physician will 
here also detect distinct induration and abnormal thickening of 
the urethra. If the disease should advance, and the bulbous 
portion of the canal be implicated in the inflammatory process, 
pain will be felt along the perinasum, especially when the patient 
undertakes to walk about. If the prostate become affected, 
the distress will be felt farther back ; there will be pain, and an 
uncomfortable degree of heat and throbbing, about the rectum, 
with tenesmus and incontinence, or retention of urine. Another 
quite frequent and annoying symptom is the occurrence of 
involuntary and painful erections at night, which interfere 
with, or wholly prevent, quiet repose. At this juncture, still 
other morbid phenomena will arise, unless those already men- 
tioned are subdued. Pains in the head, in the lumbar and 
inguinal regions will set in ; the tongue will be thickly coated, 
the pulse accelerated, the mouth parched with thirst, and the 
skin hot and dry. 

Blennorrhagia presents various degrees of severity in differ- 
ent subjects. The first attack is generally attended with the 
most acute symptoms, especially if the patient be young and 
plethoric, or of a scrofulous diathesis. In the latter class the 
constitutional disturbance is sometimes of an alarming type. 
Extensive abscesses form in some portion of the genital organs, 
or in their immediate neighborhood, accompanied with imflam- 
matory fever and irritation of the nervous system, and the 
patient's life is endangered. In those who are liable to eczema 



28 GONORRHCEA AND SYPHILIS. 

and other eruptions of the skin, the blennorrhagia is prone to 
assume a chronic character from the beginning, and is then dif- 
ficult of cure. Sometimes, notwithstanding every judicious 
medical attention, the complaint progresses steadily, from day 
to day, for several weeks, the discharge increasing in quantity, 
with corresponding augmentation of the other symptoms. In 
such cases, if the previous habits of the patient can be ascer- 
tained, it will generally be found that he has led an irregular 
life, or that he is susceptible to inflammatory affections of the 
mucous membranes ; and the system refuses to respond to the 
usual influence of anti-blennorrhagic agents. Persons who 
have had several fresh attacks of this malady suffer for a longer 
time from each successive one, although the symptoms do not 
acquire so high a degree of intensity as they do in the first 
gonorrhoea. 

Blennorrhagia often subsides into a chronic form, and termi- 
nates in blennorrhoea or gleet. The amount of discharge is 
reduced to two or three drops in the twenty-four hours. In 
some cases it is noticed only in the morning ; in others, the ori- 
fice of the urethra is constantly moistened with it, or its lips are 
sealed together a great portion of the time in consequence of 
the drying up of the exudation. The fluid is of a serous or 
mucous character. If pus globules be present, they separate 
into a pellicle by themselves, and leave a small, yellow stain 
upon the patient's linen. 

Sometimes the gleet is intermittent. It will disappear for 
several days, and then, in consequence of some imprudence, 
will again return. Any irregularity or indulgence on the part 
of the patient, or any impropriety in treatment, may result in a 
permanent establishment of this trifling but annoying secretion. 

Contagion. - — It is impossible to say at what period the spe- 
cific, contagious element ceases to form a component part of a 
blennorrhagia. It is more persistent in the female than in the 
male. Hunter mentions the case of a girl, who had been two 
years in the Magdalen Hospital, and who infected a man with 
whom she had connection immediately after she left that insti- 
tution. The only safe rule for the medical adviser to adopt in 
giving counsel to those who seek it, is this : while there is any 
morbid discharge from the genital apparatus, either in the male 



BLENNORRHAGIA. 29 

or female, the patient must be regarded as a source of conta- 
gion, so far as relates to sexual intercourse. . This is the only 
prudent ground for all parties ; and it is fit here to express a 
word of caution relative to this subject, inasmuch as there are 
Claudios in every community, — men of ardent and impulsive 
temperament, who have no control over their animal proclivi- 
ties ; and who, while a tedious gleet is upon them, propound to 
their medical attendant the question above alluded to, — and 
they will insist on a decided answer. These men sometimes 
turn out to be dangerous characters in more ways than one ; 
and the young practitioner should be on his guard how he 
replies to such inquiries. The questioner may have an ulterior 
purpose to accomplish, apart from mere sexual gratification ; 
and the moral responsibility of what he designs to do, he aims 
to shift, in part at least, upon the shoulders of the physician. 
Unless you give an unequivocal answer in the negative, he may 
commit the act ; and, if evil consequences arise, he will lay the 
sin at your door. He will upbraid you for sanctioning his 
views, and thus virtually making yourself a party to the affair. 
Such stratagems have been employed to the disadvantage of the 
young physician. 

Another subject, of greater moment than the one just spoken 
of, is frequently presented to the medical adviser for his deci- 
sion. I refer to matrimony. For instance : a young man has, 
for several months, been troubled with an insignificant dis- 
charge, which appears at the urethral orifice as a small trans- 
parent or opaque drop, every morning, or perhaps only every 
other morning. He has made arrangements to marry within a 
certain time, and any proposition for, or intimation of, postpone- 
ment, might be regarded as a strange and suspicious movement. 
He has sufficient respect for you and for the other party to seek 
your advice, which he intends to follow. Now, as an intelligent 
and conscientious counsellor, can you encourage this man's 
marriage before his blennorrhoea is cured ? It is doubtless true 
that, if the gleety fluid contain no pus cells, it can do no mis- 
chief ; and married men, who have blennorrhoea, have often 
stated that they have indulged in sexual intimacy with their 
wives, without imparting disease. One reason for this immunity 
in females, when thus exposed, is, that the inner membrane of 
the vagina is protected by the presence of abundant mucous 
3* 



30 GONORRHOEA AND SYPHILIS. 

secretion during coition ; and it is fortunate for them that this 
physiological condition exists in such a crisis. Although it is 
admitted that, in most instances, gleety secretions are harmless, 
so far as relates to contagion, yet we possess no means of deter- 
mining, in all cases, when this element is present and when it 
is not. Blennorrhea al matter is not uniform in its constitution 
in the same individual. The amount of pus globules differs at 
different times. Any high excitement will augment their num- 
ber, and sexual intercourse is one of the chief causes of this 
purulent increase. Unless a sample of blennorrhceal exudation 
were to exhibit the purity of distilled water, when examined 
with a high magnifying power, no man would be justified in the 
conclusion that it was bereft of its noxious properties. In 
announcing his opinion, it is enough for the medical man to 
know that, under certain circumstances and conditions, gleet is 
communicable. Cases are recorded of contagion thus commu- 
nicated, and giving rise to the most disastrous domestic unhap- 
piness. M. Yidal relates two such. The disease was consid- 
ered of no importance, and marriage was permitted. Separation 
of the parties was the result in both instances. 



CHAPTER H. 

TREATMENT OF BLENNORRHAGIA IN THE MALE. 

In the male subject, the anterior or balanic portion of the 
urethra is in a majority of cases the primary seat of gonorrhoea ; 
and the precise point at which the irritation commences is the 
fossa navicularis. From this focus the disease may extend until 
the canal is implicated throughout its whole length, unless an 
effectual check be put to the morbid action by what is termed 
the abortive treatment. If the patient apply to the surgeon 
within twenty-four hours from the first appearance of the dis- 
charge, the use of injections may in some instances be resorted 
to with success. In the generality of cases, it is well to order a 
brisk cathartic before commencing with other remedies. A free 
action upon the bowels by some saline medicine, will pave the 
way for beneficial results to be realized from the employment of 
injections and from large doses of balsam of copaiba or the 
powder of cubebs. In the treatment of all cases, whether by 
the abortive method or otherwise, it is important, in every stage 
of the complaint, to guard against a constipated condition of 
the alimentary canal. In this particular, advantage may be 
gained by attention to diet. The free use of oranges, dates, or 
figs, — a bowl of oatmeal gruel sometime in the after part of 
the day, will do much toward accomplishing all needful pur- 
poses in this direction. If repeated evacuant medicines be 
given, they will be liable to interfere with the digestive func- 
tions, — will render the bowels more and more torpid, — and an 
increase of the dose will be needed on every successive occasion. 
In many instances, where free purgation is resorted to, a long 
and tedious course of treatment is required. Patients of their 
own accord often pursue a cathartic plan for several weeks, and 
then report that their urethral difficulty is as troublesome as at 
the beginning. At least, there seems to be no prospect of its 
termination, in consequence of the increased action performed 

(31) 



32 GONORRHCEA AND SYPHILIS. 

by the alimentary canal. It is important, as auxiliary to more 
direct and specific measures, to maintain a decidedly open con- 
dition of the bowels ; but not to annoy the patient by constant I 
doses of sharp, drastic medicines. 

Fomentations. — As a local remedy, hot water fomentations 
exert a most favorable influence in allaying the severity of the 
symptoms attendant on acute blennorrhagia. They should be 
applied to the penis and its dependences for fifteen or twenty 
minutes, many times in the twenty-four hours. Used in the 
early stage, and at as high a temperature as can be endured 
without actually blistering the parts, they serve to lessen the 
irritability of the urethra very speedily ; — they allay the pain 
and scalding in micturition, and relieve the patient of the 
sensation of dragging weight in the testes, and about the peri- 
nseum and hips. On removing the fomentations, the parts 
should be covered with a single thickness of soft linen. I was 
first induced to try this method of applying heat and moisture 
on the recommendation of Mr. Milton.* The utility of the 
procedure in soothing the diseased organs and the patient, I 
have repeatedly witnessed. In fact, in nearly all cases where 
the fomentations have been faithfully tried, the anodyne effect 
has been immediate ; and no untoward result has ever followed. 
If there be tumefaction and pain in the glans, or if the 
patient be tormented with chordee, the employment of this 
cleanly and simple remedy will prove highly serviceable. It 
needs no addition of poppy-heads, opium, or lead. Its thera- 
peutic action cannot be improved by any medication. 

The patient should be restricted to a low diet, and directed 
to maintain entire bodily repose. By the adoption of these 
ectrotic measures, he may be saved from a long and tedious 
gonorrhoea or gleet, and from various complications', which 
occasionally appear and terminate seriously. 

Injections of Nitrate of Silver. — It was formerly believed 
that a strong solution of this salt, employed as an injection, 
occasioned stricture ; but the idea now is, among those who are 
partial to its use, that, instead of producing, it prevents that 

* It is recommended also by Mr. Acton and other surgeons. 



BLENNOKRHAGIA. 33 

accident. Whether this theory be true or false, I pretend not to 
say ; but in regard to what are called strong injections of silver, 
I can state that I never prescribe or use them. There are others 
however, who do ; and a few paragraphs must here be devoted 
to a consideration of their employment. If the injection be 
resorted to before the inflammatory stage has commenced, that 
is, before the patient complains of scalding in micturation, it 
will sometime prove an efficient agent in at once cutting short 
the disease. Of this there is ample testimony from the highest 
sources ; and there may be cases even in private practice, in 
which the measure is imperiously demanded. Ten grains of the 
salt to the ounce of rose water is the usual proportion. The 
bladder should be emptied immediately before the solution is 
employed, so that the urethra may have a chance to rest for 
several hours afterwards. A glass syringe, in perfect working 
order, is the best. One drachm of the solution will be enough.' 
As soon as the operation is completed, let the patient recline on 
a bed or sofa, and have warm fomentations applied to the parts 
for two or three hours. One injection introduced during the 
initial stage of the blennorrhagia, and allowed to remain in the 
urethra for about one minute, is sometimes sufficient to anni- 
hilate the morbid action. If the secretion still continue, and 
exhibit a puriform character, the injection is to be repeated in 
twenty-four hours, as on the preceding day. If two injections 
fail to accomplish the desired results, there will be little encour- 
agement to make a third trial with this heroic and severe prepa- 
ration. An injection of three or four grains of the nitrate to 
the ounce of water is much safer than one of greater strength. 
It can be repeated three or four times in the twenty-four hours, 
unless evident ill consequences ensue. This comparatively 
weak injection may be retained three or four minutes by press- 
ing upon the orifice of the urethra after the syringe is with- 
drawn. The manner of manipulating with this instrument is a 
matter of no small importance. The surgeon should use it 
upon the patient once or twice before entrusting it to his hands. 
The point should be inserted to the distance of an inch, and the 
injection allowed to traverse the whole length of the urethra. 
It will thus be certain to come in contact with the seat of dis- 
ease, in whatever part of the canal it may be. At the moment 
the instrument is introduced, the penis should be turned upward 



34 GONORRHOEA AND SYPHILIS. 

in nearly a perpendicular position, and the lips of the urethral 
orifice be pressed with the thumb and forefinger of the left 
hand. The untimely escape of the injection will thus be pre- 
vented. If no good effects are realized by the third day, the 
injection will not succeed at all, and should be abandoned. 

Although the abortive treatment is productive of the most 
beneficial effects in certain cases that present themselves to the 
regular practitioner, it is manifest that the number of such must 
be comparatively small. If the discharge have existed more 
than a day and a night, before the patient applies for re- 
lief, it will be too late to make trial of the revulsive method ; 
for the inflammation, in nearly all cases, will be too acute to 
justify such a procedure. The favorable moment for a fair 
experiment has been lost ; and if now the parties have courage 
and confidence to engage in it, they will but prepare the way 
for unwelcome retrospections. The discharge, instead of being 
a slight adhesive mucus, has become decidedly purulent, and 
the patient is troubled, although perhaps not severely, with 
ardor urinae and other disagreeable symptoms. This state of 
things is a declaration that the disease has reached a consider 
able portion of the urethra. Patients are not slow to importune 
the physician to adopt, at once, the most efficient course of 
treatment, with the view to a speedy cure. In their impatience 
and ignorance, and in the hour of their desperation, perhaps, 
they manifest a readiness to encounter no little hazard and 
temporary suffering, which the employment of any remedial 
means may involve, provided the disease, to use their own 
words, " can be knocked in the head." They generally have 
great faith in injections of some kind ; and in regard to their 
employment in any individual case, the exercise of a good share 
of independence, as well as sound judgment, is requisite on the 
part of the young surgeon, — otherwise lie may be unduly 
influenced by the solicitations and suggestions of the patient. 

The abortive treatment has the sanction of the most eminent 
surgeons. The most important element in it consists in the 
use of strong nitrate of silver injections. Every practitioner 
must see that this mode of assailing the disease in its hidden 
retreat is attended with risk, especially if a solution of ten 
grains to the ounce be employed. It is, as it were, attacking 
the enemy by storm. The syringe, charged with the potent 



BLENNOKRHAGIA. 35 

liquid, cannot, at any rate, be wielded by the patient with entire 
safety ; nor can the danger attending its use be essentially di- 
minished if the instrument is handled in the most adroit and 
cautious manner by the surgeon ; for, from the very nature of 
things, even he cannot regulate the precise degree of local 
impression produced by the fluid. In this particular it will 
obey no man's wishes. The instant it is forced from its con- 
finement it glides like a swift torrent along the urethra ; and 
its work, whether for good or for evil, is accomplished instan- 
taneously. 

The intense pain which always follows the application of the 
strong injection is a serious drawback upon its use. Another 
objection is, that in many instances it not only fails to benefit 
the complaint, but creates an aphthous condition of the mucous 
membrane, or sloughing ulcerations, which prove exceedingly 
troublesome, and are often more difficult to cure than an ordi- 
nary gonorrhoea. M. Vidal relates the case of a man whose 
absent wife was expected home in a very short time after he 
discovered that he had contracted a gonorrhoea. He applied 
to Vidal for a sure method of at once arresting the disease ; 
and, as that judicious surgeon could not promise this, the 
patient consulted another man, who advised a caustic injection, 
which brought on a severe inflammation of the canal and of the 
bladder. Vidal was finally requested to take charge of the 
patient, who was confined to his bed for a month in conse- 
quence of the over-action of the injection. Langston Parker 
mentions the case of a medical student who contracted a blen- 
norrhagia, to cure which he used in the incipient stage a 
strong solution of silver. An intense urethritis followed, with 
pains in the abdomen and groins. The young man had peri- 
tonitis and an immense inguinal abscess, of which he died in 
one week. 

From the moment the use of the syringe is commenced, an 
exacerbation of the urethral inflammation is liable to ensue; 
the discharge also increases, and in some instances the testes 
suddenly enlarge to three or four times their normal size. 
Some patients, not of a sanguineous temperament, will tolerate 
stimulating, and even somewhat caustic, injections with impu- 
nity — perhaps with advantage ; but if in any given instance 
a peculiar susceptibility should exist, the fact cannot be known 



36 GONORRHOEA AND SYPHILIS. 

until the remedy has been tried. In such a case, although 
the lesion may occupy but a mere point before the injection 
is introduced, it may immediately afterwards, and as a direct 
consequence, extend indefinitely to the sound portions of 
the canal. The spontaneous tendency of the disorder is to 
spread along the mucous membrane, and even to penetrate 
the deeper tissues ; and any auxiliary impulse from the hands 
of the patient or physician might augment the mischief. If 
the surgeon can have entire control over the patient, and be 
certain that his directions will be carried out to the letter, — 
as, for instance, where the case is admitted within the walls of 
a well-regulated hospital at a seasonable time, — then the abor- 
tive treatment may be entitled to all the confidence, praise, 
and success which its advocates claim for it ; but, for ordi- 
nary private practice, too many objections lie in the way of its 
adoption. 

Balsam of Copaiba. — No article in the Materia Medica 
enjoys a higher reputation for the cure of blennorrhagia than 
this. For many years it has been a favorite remedy both in 
public and private practice. The late Professor Chapman, of 
Philadelphia, was the first physician in this country to recom- 
mend the balsam in the early stage of gonorrhoea ; and on his 
authority physicians generally were induced to prescribe it. Its 
anti-blennorrhagic powers have been most amply tested and 
universally acknowledged. In very plethoric subjects, who are 
accustomed to high living, it is well to relieve the inflammatory 
symptoms, in the early period of the urethritis, by a smart 
saline cathartic, before commencing its use. This class of 
patients occasionally suffer from the severest forms of the 
disease, accompanied with intense pain as one of the most 
prominent features. In such circumstances, the case should 
be conducted for a short time on a strictly antiphlogistic plan, 
without reference to the specific cause in which it originated. 
As soon as the local symptoms have abated, the copaiba and 
other anti-blennorrhagic remedies will be appropriate. Cases, 
however, requiring such antecedent preparation, are very rare. 
In the great majority of subjects, the occurrence of painful 
erections, chordee, scalding in micturition, and other concomi- 
tants of inflammation, constitute no barrier to the immediate 



BLENNORRHAGIA. 37 

use of the balsam with as much freedom as the stomach and 
bowels will tolerate ; for no other remedy can be selected that 
is so well adapted to allay these phenomena, and relieve the 
patient of the sufferings which they inflict. It might at first 
view seem paradoxical that an ingredient endowed with such 
decided stimulating qualities should be beneficial under such 
circumstances, but experience has abundantly established the 
fact. It has long been known by many practitioners to exert 
a salutary effect in some other diseases of the genito-urinary 
passages. In strangury from blisters, and in leucorrhcea, it 
may often be administered with signal relief to the patient.* 
Although, when given internally, it may be regarded almost as 
a specific in urethral blennorrhagia, its therapeutic qualities are 
confined to this variety of the disorder. Its modus operandi is 
not well understood. 

When copaiba acts as a purgative, the urethral discharge will 
frequently be very much diminished, — sometimes will entirely 
cease ; but it will usually immediately return as soon as the 
revulsive action upon the alimentary canal subsides. 

In order to secure its best effects upon the gonorrheal affec- 
tion, it is frequently advisable to combine it with some astrin- 
gent or sedative. 

There is a great disparity in the purity and curative value of 
different samples of the medicine in question. It is often 
adulterated and rendered unfit for use by being mixed with 
rape-oil. When thus adulterated, if dropped into water, the 
drops do not retain their spherical form, as they invariably do 
in the pure state. f Professor Redwood, of London, states that 
the oleo-resinous properties of the balsam exist in very different 
proportions in different samples. The quantity of volatile oil 
has been found to be twice as great in some samples as in 
others. In order to estimate its purity, the article must be 
resolved into its proximate constituents, and these be examined 
separately. The proportion of volatile oil in different samples, 
met with in commerce, is, in some cases, as low as thirty per 
cent., and, in others, as high as sixty per cent. ; and the propor- 
tion of resin, which differs but little from common resin of tur- 

* Vide Chapman's Therapeutics, vol. L, p. 416. 
•]• Journal de Pharmacie et de Chimie, vol. xi. 

4 



38 GONORRHCEA AND SYPHILIS. 

pentine, varies also to about the same extent. If a drop of the 
balsam be allowed to fall upon sized paper, and then dried by a 
gentle heat, the odor of the turpentine can easily be detected 
during the evaporation, if it has been adulterated.* 

To some persons, the taste and odor of the copaiba are ex- 
tremely offensive, a circumstance which may greatly interfere 
with its use ; and it is difficult to know how to give it so that 
the stomach of such individuals will not reject it. It is retained 
best if taken about half an hour after meals. The eructations 
are thus rendered less offensive. It may be taken in coffee or 
wine ; or, what is perhaps better, let about a drachm of the 
compound tincture of cinchona be put into half a gill of water, 
and then drop in the copaiba. It will rise to the surface in the 
form of a globule, and can be swallowed by most patients with- 
out offending the gustatory apparatus. But a still more agree- 
able and convenient method of administering it is the follow- 
ing : — 

R. Copaibae, §iij. 

Spiritus iEtheris Nitrici, ........... §ss. 

Tincturae Kino, §ss. 

Misturae Camphorae, §ij. 

Morphiae Sulphatis, gr. iv. M. 

Dose. — One teaspoonful three times a day. 

Usually, an efficient check will be put to the blennorrhagia 
in eight or ten days by the use of this preparation. No medi- 
cine is more prompt or certain in its action than the balsam, 
although it is difficult entirely to disguise its nauseous quality 
by any vehicle in which it may be given. With the exception 
of its bad taste, it is as exempt from objections as 'any other 
remedy. If taken with ordinary prudence, it never gives rise 
to any serious accident. It produces no stricture, no chordee, 
no swelled testicle, no irritation of the bladder, no gleet. Pa- 
tients have taken two, four, and eight drachms at a dose, morn- 
ing and night, at the very onset and in the most acute stages 
of gonorrhoea, with entire success and without any prepara- 
tory treatment. Such doses, however, are not safe. Instances 
are recorded where large quantities have been resorted to 

* Dublin Quarterly Journal of Medicine, vol. v. 



BLENNOKRHAGIA. 39 

by the patient, on his own responsibility, and the result has 
been an increase of the urethral inflammation and discharge. 
Incontinence of urine has been induced by excessive doses. A 
few years ago a gentleman from the South consulted me for a 
recent gonorrhoea. He had taken lodgings at a large hotel in 
company with some friends, and for fear of being detected, he 
desired that a cure might be accomplished in the most summary 
manner. I prescribed the balsam in half drachm doses three 
times a day. Instead of following the directions, the patient 
took nearly half an ounce after a supper of oysters, and at a 
late hour went to bed. It was not long before he was seized 
with a sort of cholera morbus, — that is, he had griping pains 
in the stomach and bowels, — vomiting and purging, which 
lasted several hours. His urethral trouble vanished and did 
not return. The severe gastro-enteric attack doubtless served 
as a coup-de-main in extinguishing it. 

When a person applies for treatment and is particularly anx- 
ious to be speedily rid of his gonorrhoea, he should be advised, 
as already stated, to abstain from exercise. If he would be 
delivered from his trouble in the shortest possible time, he can 
receive this boon only by keeping still ; and unless he conform 
to this condition, it will be a vain task to attempt a rapid cure 
by any course of treatment. The mere fact that the individual 
is abroad, whether on business or pleasure, will effectually pre- 
vent any remedies from accomplishing a speedy removal of his 
blennorrhagia. And it is the province and the policy of the 
medical attendant to state these things in the most explicit 
manner. If the man be unable or unwilling to pursue the 
plan proposed, he should be distinctly informed that the time 
requisite for his cure admits of no sort of calculation. It may 
be several weeks, or it may extend to many months ; and all 
this, because a few important items in the management of the 
case have been disregarded. In adjusting preliminaries, a good 
understanding between the parties should exist. The physician, 
from the very fact that he takes charge of the case, pledges him- 
self, -by a moral contract, to employ the best means within his 
knowledge for the benefit of his patient ; and the latter, on his 
part, is under equal obligation to cooperate with the physician 
in carrying out the prescribed treatment. By the observance of 
such an arrangement, a safeguard is created against all future 



40 GONORRHOEA AND SYPHILIS. 

collision, which might otherwise spring up and seriously disturb 
the amicable relations of the two parties. 

Among those who seek the aid of the surgeon for the cure 
of disease resulting from improper commerce with the opposite 
sex, it need scarcely be said that a troublesome fellow now and 
then presents himself, who does not hesitate to take advantage 
of his medical adviser, in some way or other, especially if the 
latter be a young practitioner. Some individuals are extremely 
exacting, and will wittingly endeavor to extort strong assurances 
as to a cure ; and afterwards, if the treatment do not progress 
favorably, they will allude to some casual expression that 
escaped the physician, and charge him with a lack of skill, while 
they themselves, from recklessness or something worse, have 
been doing little else than placing barriers in his way, and 
defeating the best and most assiduous efforts which he has 
employed in their behalf. In such cases — and I have certainly 
known such — the physician does every thing within the range 
of medical science, while the captious patient does next to noth- 
ing in the right direction. These remarks are not a mere irrel- 
evant digression. They have been suggested by the fact, that 
young surgeons somewhat frequently express regret that in 
identifying themselves professionally with cases, they have, from 
sentiments of delicacy, or from apprehension of losing practice, 
omitted to enforce the claims due to them from the patient, and 
in consequence of their pusillanimity have experienced nothing 
but disappointment and loss. But let us return to the consider- 
ation of the direct physical treatment. 

Capsules of Copaiba. — Individuals are occasionally met 
with who cannot use the liquid balsam. The stomach refuses 
to retain it, or perhaps no little gastric distress is experienced, 
although the medicine may not be vomited. In such cases the 
remedy can be administered in capsules,, and its objectionable 
qualities will be less likely to disturb the patient. They should 
be taken soon after eating, and as freely as the stomach will 
bear. Capsules, containing a combination of copaiba and the 
extract or oil of cubebs, are kept by all good druggists ; and 
sometimes I have found them more efficient than those composed 
of copaiba alone. 

Where it may be deemed important to employ, with the 



BLENNORRHAGIA. 41 

copaiba, remedies that exert an anodyne influence upon the 
organs, as well as a modifying agency upon the qualities of the 
urine, the subjoined formula will be found useful : — 

R Copaibae, - 5vj. 

Magnesiae Calcinatae, 5 iss. 

Extracti Hyoscyami, 5 ss. 

Pulveris Camphorae, 3j. 

Theriacae, , 5 iij- 

Micae Panis, § iss. 

M. ft. electuarium. Dose : One drachm three times a day. 

This is a favorite prescription of Mr. Acton. He claims for it 
that the magnesia neutralizes the urine, that the hyoscyamus 
allays irritation of the bladder or prostate, and that the cam- 
phor checks any disposition to involuntary erections, which, 
without it, often become a troublesome complication. A com- 
bination of the balsam with the powder of cubebs makes a good 
compound, and may be employed according to the annexed 
prescription : — 

R. Copaibas, 

Pulveris Cubebae, aa, § j. 

Liquoris Potassae, 5 iij- 

Misturae Camphorae, § iv. 

Aquae Cinnamomi, § ij. 

Morphiae Sulphatis, gr. ij. M. 

Dose. — Two drachms three times a day. 

In whatever form or combination the balsam is administered, 
the patient should be directed to continue its use in gradually 
diminished quantities for ten or twelve days after the blen- 
norrhagia has entirely ceased. 

Copaiba as an Injection. — The repeated experiments of 
Ricord, Egan, and others, tend to show, that the balsam of 
copaiba, when employed as an injection, has no power to arrest 
gonorrheal secretion, nor to allay the irritable and inflamed 
condition of the urethra. The theory is, that the remedy re- 
quires to undergo a certain modification, which can only be 
effected by its transit through the kidneys, before it can exert 
any salutary effect on the urethral disease. What this trans- 
4* 



42 GONORRHOEA AND SYPHILIS. 

formation or change is, has never been demonstrated. Very 
recently, statements have been made by M. Dallas, of Odessa, 
and by Dr. Dick, of London, to the effect that they have 
employed the balsam as an injection in gonorrhoea with com- 
plete success. The former surgeon reports sixteen cases treated 
thus, without any auxiliary measures. The latter gentleman 
states, that for the last two years he has employed the copaiba 
as an injection with excellent benefit. He has also tried the 
oil of copaiba, which, he says, answers extremely well. For 
the last mentioned substance, the following is his formula : — 

R. Olei Copaibae, 5j- 

Pulveris Acacue, 5 ij- 

Aquas Fontanae, 5 vj. M. 

In subacute gonorrhoea and in gleet, this injection may 
be used twice a day for a few days ; afterwards more fre- 
quently. 

Successful results have been reported of the balsam when 
used as an enema for patients who could not tolerate it on the 
stomach. I have never made trial of it in this manner ; but 
Velpeau speaks favorably of it when thus administered. The 
following prescription can be employed : — 

R. Copaibae, 5ij. 

Mucilaginis Acaciae, § iss. 

Tincturae Opii, 5 ss. M. 

For an enema, which may be repeated two or three times in 
the twenty-four hours. 

Cubebs. — The reputation of this therapeutic agent, in exert- 
ing an immediate and favorable specific action upon the lining 
membrane of the urethra in all stages of blennorrhagia, is fully 
established ; and by many surgeons it is more frequently pre- 
scribed for its cure than any other article in the materia medica. 
The dried, unripe berries, are the officinal portion. Like the 
balsam of copaiba, they possess stimulating qualities, which are 
particularly exerted upon the urinary organs. They occasion 
constipation in some patients ; in others, just the reverse. 

The berries of cubebs are sometimes adulterated with com- 



BLENNORKHAGIA. 43 

mon black pepper. They deteriorate by age ; and, in powder, 
become rapidly weaker in consequence of the escape of their 
volatile oil. They should, therefore, be kept whole ; or, if pul- 
verized, should be preserved in a glass jar with a close stopper. 
Of the powdered berries the patient may take one or two 
drachms three times a day in a gill of milk or water. Or, the 
powder may be used in what is called the enchanted wafer, a 
French article found in many drug stores. I have prescribed 
the remedy in question alone, and variously combined with 
other ingredients. The annexed formula I have commonly 
employed for the last few years : — 

R. Pulveris Cubebae, § viij. 

" Cinnamomi, 3j. 

" Aluminis, §j. 

M. Div. in chart. No. xxxij. Dose. — One powder three times a day. 

This combination of cubebs and alum will usually diminish 
the urethral discharge in two or three days ; and if the patient 
will comply with the suggestions already given in regard to 
absolute rest, he will find that in eight or ten days his blennor- 
rhagia will be nearly at an end. But let him recollect that 
first of all things, he should make up his mind to observe a 
perfectly quiet state of body ; and even to keep in a recum- 
bent posture if he expects to experience the best effects in the 
shortest time. I have occasionally heard physicians speak, 
with self-complacent air, of making rapid cures in the majority 
of instances that come under their charge. Such success may 
have happened ; but when it has, I am sure that the strictest 
avoidance of exercise must usually have constituted an ele- 
ment or condition in the treatment. The precise time requi- 
site for a complete and permanent restoration of the parts to a 
normal state, is as uncertain as the winds ; and in specifying 
the number of days, within which to cure a given case, the 
young practitioner had better show his wisdom by his pru- 
dence. 

As with the balsam copaiba, so with cubebs ; they should 
not be discontinued under a fortnight after the cessation of 
the urethral discharge. Some excellent surgeons give two 
ounces of the cubebs in the twenty-four hours. This, it seems 
to me, is an excessive quantity, and not entirely safe. Well- 
authenticated instances have been reported of hernia humoralis 



44 GONORRHOEA AND SYPHILIS. 

being induced by large doses of the powder, while the blen- 
norrhagia was thick and puriform, with scalding in micturition, 
chordee, etc. In one case, the dose was two drachms, four 
times a day. The disease was suddenly arrested, and swelling 
of the testicles, with much inflammation of the cord, super- 
vened. The patient was confined with this complaint for two 
months. On the subsidence of the glandular affection, the 
blennorrhagia re-appeared ; was again puriform and thick, but 
not attended with urethral pains. Subsequently the discharge 
yielded to small doses of the cubebs. Another instance of 
gonorrhoea, accompanied with severe scalding, was treated 
with cubebs ; the discharge was suppressed ; but acute inflam- 
mation of one of the testicles and cord succeeded. There was 
great effusion into the tunica vaginalis of the testes, and sup- 
puration was threatened.* Accidents, however, from the use 
of cubebs, are extremely rare. Some physicians imagine that 
they are not well adapted to cases in the acute stage, where 
the inflammation runs high. It is always the more prudent 
course to order the patient a cathartic, after the operation of 
which, he may commence with the cubebs, without regard to 
the degree of urethral inflammation that may be present, un- 
less it be of the most intense description. I have many times 
tried the article with plethoric subjects, and have never seen 
any trouble from its use, nor had occasion to regret that it had 
been employed. 

Cubebs will sometimes speedily arrest blennorrhagia under 
very unfavorable circumstances, as will be seen by the follow- 
ing case, which is an exception to the general rule. 

October 1, 1856. — A gentleman, thirty-six years of age, un- 
married, consulted me for the cure of an acute gonorrhoea, 
which had troubled him for eight days. He had all the ordi- 
nary symptoms of the complaint, — scalding, the glans swollen 
and of a fiery red color, oedema of the lips of the meatus, and 
copious, puriform secretion, sense of dragging weight in the 
scrotum, etc. He was a stout, athletic man, actively engaged 
in out-door business in co-partnership with another person ; 
and he stated that it would be impracticable for him to omit 

* Med. Chir. Review, vol. xxiii. p. 550. 



BLENNORRHAGIA. 45 

work for a single day, as this would lead to inquiry and per- 
haps to exposure, — that if I would prescribe a proper line of 
treatment, he would be content. As to the time that might be 
required to accomplish a cure, and in regard to any ill results 
that might ensue in consequence of his not abstaining from 
business, he would take his chance, and would absolve me 
from all responsibility. He resided more than one hundred 
miles from Boston, and could not conveniently see me until 
several weeks. The following powders were ordered : — 

ft. Pulveris Cubebae, . § xij. 

" Cinnamomi, 5 iss. 

" Aluminis, : § iss. M. 

Dose. — Two drachms three times a day in water. 

He took the powders for five days, when his blennorrhagia 
and its accompaniments wholly disappeared. He discontinued 
the medicine as soon as the urethritis ceased. This was con- 
trary to the directions given him. He did not abate his ac- 
tivity in business for a single hour. In three months after the 
gonorrhoea was cured, he discovered a gleet amounting to two 
or three drops during the twenty-four hours, — of thin, trans- 
parent, glutinous fluid, that did not stain his linen. For this 
secretion, he resumed the above medicine, of which he had a 
supply. After a trial of it for nearly three weeks without re- 
lief, he called a second time for advice. He was directed to 
take from six to eight capsules of balsam of copaiba and oil of 
cubebs, per diem, for the gleet ; and in fifteen days after com- 
mencing with them, was well, and had no relapse. 

The tincture is an elegant and convenient form of adminis- 
tering cubebs. It may be given in doses of one or two drachms, 
four or five times a day ; or be combined with other agents of 
well-known efficacy in gonorrhceal affections, thus : — 

ft. Tincturae Cubebae, § ij. 

" Cantharidis, § iss. 

Misturse Camphorae, § iij. 

Morphiae Sulphatis, gr. ij. M. 

Dose. — Two drachms three times a day, in half a gill of cold water. 

There is one other preparation of cubebs, which contains all 
the medicinal properties of the berry, and may be combined 
with mucilage, so as to constitute an agreeable and efficient 



46 GONORRHOEA AND SYPHILIS. 

dose. I refer to the fluid extract, which may be prescribed 
thus : — 

R. Extracti Cubebae, | iv. 

Mucilaginis Acaciae, 

Misturae Camphorae, aa, § ij. 

Morphiae Sulphatis, gr. ij. M. 

Dose. — Two drachms three times a day, in half a gill of cold water. 

Some medical men are altogether skeptical as regards the 
curative properties of cubebs ; but I am confident that those 
who do not acknowledge its value in cases of blennorrhagia, 
cannot have made a fair trial of the pure article. Specimens 
of the pulverized berries, that have deteriorated from having 
been exposed in large jars, imperfectly closed, are occasionally 
met with in druggists' shops. If such a medicine be prescribed, 
no wonder that it leads to disappointment and distrust. 

Besides the prescriptions already given for the use of bal- 
sam of copaiba and cubebs, other combinations may be tried in 
cases that resist the more simple and ordinary formulae. The 
subjoined note embraces several prescriptions which may be 
found useful. 

Note. — Buchu has the reputation of being gifted with anti-gonorrhoeal 
powers. Mr. Henry Hancock, recently attached to the British Army, states 
that he has treated, within a twelvemonth, more than one hundred cases of 
blennorrhagia by the administration of the infusion of the leaves, with entire 
success ; rarely having recourse to injections, excepting where the disease had 
been neglected. — London Lancet, December, 1856. 

The copaiba may be taken with the oil of cubebs, and in some cases will be 
found to agree better with the stomach than the capsules, or any other combi- 
nation : — 

R. Copaibae, § ss. 

Olei Cubebae, 3 ss. 

Liquoris Potassae 3 iij. 

Spiritus Myristicae, § ss. 

Misturae Camphorae, §j. M. 

Dose. — Two table-spoonfuls, three times a day. — Druitt. 

In chronic gonorrhoea, or gleet, the balsam and the cubebs may be advanta- 
geously given with preparations of iron : — 



BLENNORRHAGIA. 47 

ft. Pulveris Cubeba?, § ss. 

Copaibas, 5ij. 

Ferri Sulphatis, . . . . „ 5j. 

Terebinthinas Chias, 5iij. M. 

To be made into boluses of ten grains each. Dose. — From fifteen to 
thirty a day. Usefully employed in lax constitutions. 

The cubebs may also be given in powder with the carbonate of iron : — 

ft. Pulveris Cubebas, 5 j ad 5 ij- 

Ferri Carbonatis, . . . 3 ss ad 3j- 

M. ft. pulv. This mode of administering cubebs is much and successfully 
employed after the acute symptoms of a blennorrhagia have subsided. A 
powder should be taken three times a day. — Langston Parker. 

ft. Copaibas, . . . •. §iss. 

Magnesiae Calcinates, 5j. 

Pulveris Aluminis, gr. xv. 

" Catechu, 3 iss. 

" Opii, gr. xv. 

Spiritus Menthas Piperitas, 

" Canellas, aa, gtt. xl. M. 

For an electuary. M. Beyran administers this electuary in subacute gonor- 
rhea, at the commencement of the discharge, and before the inflammation has 
extended throughout the urethra ; also in the gleet. The dose is a teaspoon- 
ful three times a day, in a moistened wafer. When the discharge is arrested, 
the dose is to be gradually diminished. — Union Medicate, August, 1855. 

The formula now used at Bartholomew's Hospital is : — 

ft. Copaibas, gtt. xv. 

Misturae Acacias, fl 3 j. 

Cubebas, 3j. 

Spiritus JEtheris Nitrici, gtt. xx. 

Misturae Camphorae, 3 x. M. 

The above quantity is to be taken thrice daily. It is a standard prescrip- 
tion at the above institution. It is also ordered for females, when it is 
thought necessary to administer copaiba to the latter class of patients. — 
Holmes Coote, on Syphilis. 

The foregoing preparations of copaiba and cubebs are not materially different 
in their specific action. Either of them is sufficient to cure all ordinary cases of 
uncomplicated blennorrhagia, and no ill consequences will be entailed upon the 
patient. But let him remember that to secure the most speedy and desirable 
results, he must cooperate in all well-directed therapeutic and hygienic meas- 
ures. In such circumstances the skill of the surgeon will seldom be thwarted, 
and there will rarely be occasion to resort to an endless succession of remedies. 

RELAPSES IN GONORRHOEA. 

Notwithstanding the repeated cautions given to patients not 
to discontinue the use of remedies until several days after the 



48 GONORRHOEA AND SYPHILIS. 

cessation of the blennorrhagic discharge ; and, notwithstanding 
our advice to them not to respond to the calls of business or 
pleasure, they will, either from necessity or recklessness, disre- 
gard the warning ; and, as a consequence, the enemy will sud- 
denly re-appear, and the battle, which had apparently resulted 
in triumph, must be repeated. 

It frequently happens that this last condition is worse than 
the first ; for the morbid action, now re-established, will in all 
likelihood be more persistent, and the indiscretion of the patient 
may have laid the foundation for an interminable gleet. In 
cases of recurrence, the inflammation is less intense than at 
first, but it occupies a larger portion of the mucous membrane, 
extending probably to the posterior part of the canal. It also 
penetrates into the deeper structures ; and, whatever method of 
treatment is instituted for its removal, the remedies are gener- 
ally less efficacious than in the early period of the disease. The 
individual himself is also in a less favorable condition. He has 
become impatient and fretful ; is less buoyant with hope, less 
confiding, less respectful, less inclined to carry out any measure 
that may be required by the new state of things which exists, 
and is now, more than ever, rebellious to all restrictions. Noth- 
ing goes right. 

The following instances of relapse are taken from my record 
book. 

Case I. — January 3, 1856. Patient, a young, unmarried 
man. Gonorrhoea noticed twenty hours ago. Third attack. 
Discharge moderate, and scarcely purulent. No pain or scald- 
ing in micturition. Lips of meatus oedematous and pouting. 
No other symptoms. 

R. Pulveris Cubebae, 1 viij. 

" Cinnamomi, 5j. 

« Aluminis, §j. M. 

Dose. — Two drachms three times a day, in a gill of water. 

Jan. 7. Stomach revolts at the medicine, which was discon- 
tinued, and copaiba capsules substituted, — two, morning, noon, 
and night. Jan. 19. Gonorrhoea stopped. Patient has in part 
refrained from his usual active habits ; but states that he must 



BLENNORRHAGIA. 49 

now fully resume his employment, which is that of a clerk. 
Would continue the capsules. Jan. 25. Discharge has re-ap- 
peared more copiously than ever. There is no scalding, no 
pain, no involuntary erection, no chordee. Cubebs and alum, 
as at first, resumed; and, as auxiliary, the following injec- 
tion : — 

ft. Plumbi Acetatis, 

Zinci Sulphatis, aa, gr. iij. 

Aquae Rosarum, § vj. M. 

Use with a glass syringe three times a day. 

February 20. Discharge has ceased, excepting a drop or two 
in the morning, for the last five days. Injections and powders 
omitted ; cantharidal collodion applied to penis. This was 
repeated three times, when the gleet wholly disappeared. 

Case II. — Acute gonorrhoea — suspension of discharge — 
recurrence — cure — suppurating bubo in both groins. 

January 10, 1856. Patient aged twenty-five; unmarried; 
remarkably robust. Gonorrhoea ten days. First attack. 
Thought it would cure itself, but, as it became urgent, he 
took alarm and sought advice. Discharge profuse and puri- 
form ; severe scalding ; prepuce inflamed and excoriated ; no 
chordee ; inguinal glands somewhat enlarged, but without pain 
or tenderness. Patient had kept at his business as clerk " down 
town." Said that, come what might, he could not absent him- 
self from his post then. He took a dose of sulphate of magne- 
sia, after the operation of which, he was put upon the use of 
the compound cubebs powders, — six drachms per diem, — low 
diet. Jan. 18. Discharge has diminished one half. Other 
symptoms improved satisfactorily, except the inguinal swellings, 
which remained stationary. Patient got leave of absence for 
one week, during which he remained quiet at his boarding- 
house. Was advised to take the powders night and morning ; 
and at noon, two copaiba capsules. February 5. Blennorrhagia 
has ceased. Inguinal enlargement on the increase, with fre- 
quent, sharp pains. Continue internal remedies in half quan- 
tities. Tincture of iodine and hot fomentations to groins. 
Patient is compelled to return to his place of employment. 
5 



50 GONORRHOEA AND SYPHILIS. 

Feb. 13. Discharge has re-appeared. No scalding, no chordee, 
no urethral pains. Inguinal glands still enlarging, and are 
painful. 

R. Capsules of copaiba and oil of cubebs, . . . No. viij.^er diem. 
And as an injection : 

R. Plumbi Acetatis, 

Zinci Sulphatis, aa, gr. iv. 

Aquse Fontanse, . § viij. M. 

The urethral discharge degenerated into a gleet. To cure 
this, one application of cantharidal collodion proved sufficient. 
After an interval of three months from the commencement of 
the gonorrhoea, the inguinal glands suppurated, and nearly 
three months more elapsed before the abscesses entirely healed. 

Case III. — Mild gonorrhoea — suspension of discharge — 
frequent relapses produced by sexual indulgence — final cure. 

October ', 1855. A. B., a married man, aged thirty-two. 
Strong and healthy ; an ardent devotee at the shrine of Venus 
for many years, and this was his third gonorrheal visitation. 
It came on three days before I was consulted. Discharge mod- 
erate and muco-purulent ; slight ardor urinae ; glans inflamed 
and tumefied. Patient was connected with an extensive trading- 
house ; and, in making arrangements for treatment, he stated 
that he could not absent himself from business for a single day. 
All he wanted was, that the best course might be adopted which 
the circumstances would allow, and he would find no fault, 
whatever might be the result. He asked for something to take 
that had no smell, and the capsules of copaiba and oil of cubebs 
were prescribed. These he took as freely as the stomach would 
bear, and in three weeks the urethral symptoms disappeared. 
Soon after this, he had connection with a woman for several 
successive nights. The discharge returned, and the capsules 
were renewed ; the lead and zinc injections were also recom- 
mended. At the expiration of about another three weeks the 
blennorrhagia again stopped ; and the infatuated man renewed 
his libidinous habits. Thus a succession of indulgence, relapse, 



BLENNORRHAGIA. 51 

and cure took place some seven or eight times in the space of 
about as many months. The patient was at last convinced that 
he must either forego the beastly indulgence "of his sensual 
appetite, or abandon the idea of permanent exemption from his 
blennorrhagic trouble. Accordingly, he abstained from sexual 
intercourse ; and the urethral affection, which had now for 
some weeks been a mere gleet, received a final coup-de-grace 
through the efficient agency of cantharidal collodion, which 
was twice applied to the offending organ. The patient assures 
me that, since his recovery, he has kept out of harm's way. 



Case IY. — Acute gonorrhoea — suspension of discharge — 
cure — spermatorrhoea supervening — cure. 

December 26, 1855. L. S., aged eighteen years. Tall, slen- 
der frame, constitution delicate. By day, doing business in the 
city ; at night, is ten miles in the country by railroad. Blen- 
norrhagia eight days, profuse, yellow, puriform ; severe scalding 
in micturition ; painful erections and chordee. Compound 
cubebs powder, six drachms a day. Had taken a saline ca- 
thartic on the previous day. Patient remained quietly in the 
country for twelve days, when the blennorrhagia ceased, and he 
went to his place of business, where his services were urgently 
demanded. In five days the blennorrhagia returned. To arrest 
it, balsam of copaiba mixture was prescribed. In ten days the 
running again ceased, excepting a drop of thin, transparent 
mucus in the morning. For this, injections were employed as 
in Case II., together with cantharidal collodion to the integu- 
ment of the penis. In twelve days the abnormal secretion 
made its final disappearance. 

In just five- weeks from the time the patient reported that the 
gleet had vanished, he called to be cured of spermatorrhoea. 
He stated that, a few days previous to the disappearance of the 
gleet, he began to be troubled with undue sexual emotions and 
involuntary nocturnal emissions. The latter had gradually 
increased in frequency, until they numbered ten or twelve in a 
week, and were coincident with erotic dreams. He was pallid, 
nervous, dejected ; had a poor appetite ; strength reduced, and 
bowels constipated. He was directed to use a generous diet, to 
bathe in cold water daily, to take free exercise in the open air, 



52 GONORRHOEA AND SYPHILIS. 

and, as a tonic and aperient, equal parts of the wine of iron and 
syrup of senna to the amount of two or three drachms each 
day ; at bedtime, a drachm of lupulin. These directions were 
all faithfully observed. The spermatorrhoea gradually subsided, 
and at the end of eight weeks gave no further trouble. 

Abnormal sexual excitement and involuntary seminal emis- 
sions are frequently met with in chronic blennorrhagia. In 
such cases, the engorgement and irritation of the prostate gland, 
and deeper portions of the urethra, are propagated to the vesic- 
ulse seminales, and hence the disturbance of their physiological 
function. 

Every physician and surgeon is naturally more deeply im- 
pressed with what he sees and witnesses within the range of 
his own field of professional service than with what transpires 
within the limits of another man's practice. But the history of 
blennorrhagia, as known and treated by various practitioners, 
shows that it is curable through the instrumentality of a great 
diversity of remedies, no one of which is entitled to the charac- 
ter of an absolute and infallible specific. The disease differs 
greatly in the severity of its symptoms as developed in patients 
of different constitutions and different habits ; and although its 
leading features are sufficiently marked to enable the practi- 
tioner to recognize it, yet he will find it a futile attempt if he 
undertake to employ a uniform mode for all cases. But, al- 
though the malady yields to no specifics as such, there is a great 
choice of remedies, just as we find in other complaints, in the 
management of which our means are applied according to the 
daily assemblage of symptoms. In attempting the cure of 
blennorrhagia, some surgeons employ the balsam of copaiba 
almost exclusively ; some trust to cubebs as being best adapted 
to the greatest number of cases ; some rely on a combination 
of copaiba and cubebs, in the belief that the virtues of the two 
remedies are best exerted when united ; some resort to antiphlo- 
gistics, some to injections, with no other treatment ; and others, 
still, bring into service nearly all the above measures in the 
same case, and, in addition to this, are sometimes obliged to 
vesicate the penis or perineal integument. All these plans of 
treatment succeed ; all occasionally fail. 

Dr. Charles A. Davis, the intelligent and efficient surgeon of 
the United States Marine Hospital at Chelsea, near Boston, 



BLENNORRHAGIA. 53 

informs me that, during the last three years, he has treated 
about eighteen hundred cases of gonorrhoea at that institution, 
and that he has given various modes of treatment a fair trial, 
including every new remedy that has come to his notice. In 
the abortive treatment he has employed the strong solution of 
nitrate of silver, keeping the patient confined to his bed, and 
restricting him to a low diet, for a few days. If the period has 
passed for resorting to the abortive treatment, Dr. Davis orders, — 

R. Copaibae, 

Mucilaginis Acaciae, aa, |iv. 

Aquae Camphorae, § xv j« M. 

Dose. — Half an ounce three times a day. 

In chronic blennorrhagia and in gleet he very generally 
applies the cantharidal collodion, which in almost every in- 
stance brings satisfactory results. In private practice it would 
of course be equally successful, provided it were convenient to 
use it ; but there are too many obstacles, too many contingen- 
cies, that will in many cases arise in the way of its employment. 
The objections lie chiefly with the patient himself. He dreads 
the pain ; nor will he submit to the inconvenience and restraint 
which its application imposes. 

Injections in blennorrhagia. — Although the idea of curing 
blennorrhagia, in its initial stage, in conformity with the old 
adage, " cito, lute, et jucunde" by strong injections of nitrate 
of silver, is scarcely tenable so far as relates to private practice, 
yet, in many cases, injections of some sort may be advanta- 
geously resorted to, and without risk to the patient. As adjuncts 
to other agents in the latter stages of the disease, when the 
active inflammation has materially diminished, and the indi- 
vidual no longer complains of urethral pains, nor of ardor 
urinae, then injections of a mild, astringent, or sedative char- 
acter may be employed. They are, generally speaking, most 
opportune when anti-blennorrhagic remedies have had a fair 
trial, and have failed to arrest the discharge. So long as the 
case is doing well under the use of balsam of copaiba, cubebs, 
cantharides, or other constitutional treatment, we need not feel 
that there is any occasion to use injections. To let well enough 
alone is always good policy. Local remedies sometimes disturb 
5* 



54 GONORRHCEA AND SYPHILIS. 

the favorable action that is being produced by the agents al- 
ready at work. But, if injections have been determined upon, 
the surgeon should give directions as to the best manner of 
employing the syringe, so that its contents may pass along the 
whole length of the urethral canal ; for it is not certain, in any 
given instance, at what point or portion the disease may exist. 
The injection should be allowed to remain in contact with the 
canal for several minutes, — or until it creates a trifling degree 
of pain, — and its subsequent action should be carefully noted. 
If it increase the discharge, it should be discontinued. Ice-cold 
water may safely be thrown into the urethra several times a day 
during any stage of gonorrhoea. This can do no harm ; on the 
contrary, it often exerts a very favorable influence. In nearly 
all cases I advise the use of it many times in the twenty-four 
hours, provided the patient is so situated that he can employ 
the syringe in a proper manner. If there be much irritation in 
the urethra, an injection of cold water, with three or four grains 
of aqueous extract of opium to the ounce, may be usefully 
employed. It should be carefully filtered. 

During the last few years, Ricord has been gradually relin- 
quishing the employment of caustic injections in the treatment 
of gonorrhoea, because every now and then instances occur in 
which the pain is very severe, the artificial inflammation runs 
high ; and then, instead of a cure being obtained, the disease 
relapses into a chronic state, which resists all means of cure : 
in addition to this, the patient requires a great deal of watch- 
ing, — more than a medical man in full practice is able to 
devote to him. Ricord now prefers the capsules of copaiba, 
and the following injection : — 

R. Zinci Sulphatis, 

Plumbi Acetatis, aa, . . . gr. xv. 

Tincturre Catechu, 

" Opii, aa, gj. 

Aquse Rosarum, gvj. M. 

Injection. 

Acton states that his experience fully sustains that of Ricord ; 
and that it is only in old cases of gleet, in spermatorrhoea, and 
in chronic affections of the bladder, that he employs the nitrate 
of silver injections.* 

* Vide London Lancet, December, 1854, page 459. 



BLENNORRHAGIA. 55 

It is often advisable to vary the character of the injections ; 
I propose, therefore, in the subjoined note, to present a few 
formulae in addition to those already inserted in these pages.* 

I have thus submitted in brief ■ detail, sundry methods of 
procedure for the cure of blennorrhagia. The multiplicity of 

* R. Plumbi Acetatis, gr. ij ad iij. 

Decoctionis Papaveris, § iij. M. 

The above is to be used at night, and allowed to penetrate without restraint 
as far as the ordinary impulsion of the syringe will convey it. In four or five 
days it may be used more frequently. Used at the London Lock Hospital. — 
Henry J. Johnson. 

R. Vini Rubri, '....§ vj. 

Acidi Tannici, gr. xviij. M. 

For the male urethra. For the vagina the quantity of tannin may be 
doubled, or still further increased. — Langston Parker. 

R. Solutionis Sodae Chloridi, 5 iij- 

Aquae, % viij. M. 

This preparation is often valuable in chronic vaginal or urethral gonorrhoea 
or gleet ; and may be employed every hour or two during the day. 

R. Ferri Potassio Tartratis, 5j- 

Aquae, § viij. M. 

Injection. — For chronic blennorrhagia or gleet in either sex. Maybe 
used ad libitum. 

R. Ferri Iodidi, gr. xvj. 

Aquae Rosarum, § vj. M. 

In gonorrhoea or gleet, to be used several times a day. — Prof. Dunglison. 

R. Zinci Sulphatis, ..*.... ; 

Acidi Tannici, aa. gr. ij. 

Aquae, § ij. 

M. Injection. — To be used repeatedly during the day. — Acton. 

The tannate of zinc has been employed in the proportion of one part to one 
hundred of water, as an injection in chronic blennorrhagia with favorable 
results. 

M. Skey, surgeon to St. Bartholomew's Hospital, considers that the most 
effectual method of curing gonorrhoea and gleet, is by the use of mild injections, 
and the internal use of tincture of iron or ferro-citrate of quinine, ad libitum. 
The following is a convenient mode of prescribing the citrate : — 

R. Ferri et Quiniae Citratis, § ss. 

Syrupi Aurantii, 

Aquae Fontanae, aa, § ij. M. 

Dose. — 3j« three times a day in half a gill of cold water. 



56 GONORRHOEA AND SYPHILIS. 

remedies, constitutional and topical, shows plainly enough, how 
totally ineffectual all ordinary measures sometimes prove. Al- 
though the affection is purely local, and would seem, theo- 
retically, to admit of easy cure, yet the testimony of experience 
tells a different story ; and we learn from it, that the disease is 
now and then as obstinate as it is disgusting. 

PAINFUL ERECTIONS. 

These complications of blennorrhagia sometimes occur, to 
the great torment of the patient, especially during the latter 
part of the night ; and their immediate removal, and the pre- 
vention of their recurrence, should engage the attention of the 
surgeon. The erections are involuntary. I once knew a mar- 
ried man — a carriage painter — who had gonorrhoea, and 
whose virile organ continued in a state of priapism for nearly 
twenty-four successive hours. He could not make known his 
condition to any one, without exposing himself in a way that 
would have raised a moral hurricane in the domestic circle, and 
he continued to suffer, until a brisk cathartic, which he took, 
brought relief. 

In chordee, the penis, when in a state of tension, is curved 
downwards or to one side. The erections are much more 
troublesome during the second stage of blennorrhagia, than at 
any other period. Now and then, in nervous men, they persist 
after the inflammatory symptoms have disappeared. In the 
generality of cases, the abnormal condition takes place when the 
inflammatory action extends to the reticular tissue of the 
urethra, and consequent infiltration of plastic lymph into its 
cells occurs, whereby the canal loses its uniform elasticity, and 
cannot expand in due proportion with the distension of the 
erectile apparatus. 

Treatment. — In some cases, antiphlogistics and sedatives are 
required for the removal of this phenomenon. Leeches, and 
afterwards, cold water to the perinseum are useful. The latter 
application may be continued for several hours. It constitutes 
one of the most efficient local measures that can be employed. 
The patient should lie on a hard mattress, with a light covering 
over him. 



BLENNORRHAGIA. 57 



Lupulin. — The sedative and anti-blennorrhagic influence of 
this remedy depends upon a resinous ethero-oily principle ; 
while the bitter element yields a real tonic. I have employed 
lupulin in doses varying from one scruple to one drachm. It 
has an advantage over opium in not producing constipation ; 
nor does it create any gastric disturbance ; and, on this account, 
it is preferable to camphor. A few months since, I had a young 
man under treatment, for whom I prescribed the lupulin, of 
which he could not take over a scruple in twenty-four hours 
without experiencing an uncomfortable, stupid feeling for sev- 
eral hours ; but the erethisms, for which it was given, were en- 
tirely quieted. This patient was nervous and dyspeptic. The 
stomach tolerated the medicine perfectly well. During the past 
few years, favorable reports, in regard to the remedy, have been 
communicated to the journals by practitioners of high standing 
in this country and Europe ; and I feel justified in stating that 
the more I prescribe it, the greater is my confidence in its ability 
to control painful erections in gonorrhoea! patients. A late 
number of the Gazette des Hopitaux contains a formula for a 
pill consisting of belladonna, camphor, and lupulin, which is 
reputed to prevent at once the occurrence of painful erections, 
and invariably to allay the morbid erectile tendency of the 
genital organs. The formula is : — 

R. Extracti Belladonnas, 3 j. 

Lupulinse Recentis, 

Pulveris Camphorse, aa, 5j- 

M. ft. pil. No. xlviij. Dose. — One to four pills at night. 

Camphor. — In some patients camphor destroys or greatly 
interferes with the appetite, and for this reason it can be pre- 
scribed only for a short time in any considerable quantities ; but 
as regards its efficacy in relieving the complications under con- 
sideration, all surgeons agree ; and it will probably continue to 
maintain a claim equal to that of any other drug employed for 
the relief of the same morbid conditions. If the gum be 
selected, it may be formed into pills with the extract of lettuce, 
according to the annexed formula : — 

R. Pulveris Camphorae, 

Extracti Lactucae, aa, Bij, 

M. ft. pil. No. xx. Dose. — One to six pills at night. 



58 GONORRHOEA AND SYPHILIS. 

For chordee , common spirits of camphor, in sweetened milk, 
surpasses all other remedies. A teaspoonful of spirit may be 
taken by the patient on going to bed ; and every time he wakes 
with the chordee, let him at once rise and repeat the dose. 
Sometimes the attack can be relieved instantly by making forci- 
ble downward pressure upon the organ. In some cases, the 
chordee becomes chronic and remains for a long period after the 
blennorrhagia has disappeared, and the penis acquires the hard- 
ness of cartilage or bone. This peculiar condition, as already 
observed, is due to the presence of plastic matter in the parts, 
and is a source of constant discomfort and alarm to the indi- 
vidual. The state of things here mentioned is of rare occur- 
rence as a consequence of urethritis, and yet it is a result of 
this complaint ; and the fact is worthy of remembrance in a 
diagnostic point of view ; for the patient is apt to fancy that the 
disease is a scirrhous or cancerous affection of the organ, and 
he lives in fear as to its ultimate and dreadful termination — a 
frame of mind which the surgeon will have it in his power to 
relieve by a few explanatory words. The internal administration 
of the iodide of potassium in compound decoction of sarsaparilla, 
and the local employment of the unguentum hydrargyri cam- 
phoratum will constitute the most suitable treatment for the 
removal of the singular accident in question. The iodide-of- 
lead ointment will also be worthy of a trial ; likewise, the appli- 
cation of small blisters and of the compound tincture of iodine. 
The deformity never interferes with the general health, although 
it does with the physiological functions of the member ; and in 
some instances it remains incurable. 

URETHRAL HAEMORRHAGE. 

In certain cases of acute blennorrhagia, attended with fre- 
quent priapism and severe spasmodic chordee, bleeding takes 
place from the vascular apparatus of the urethral canal. The 
quantity of blood thus discharged is usually small, and seldom 
gives occasion for the services of the surgeon to arrest it. In 
fact, the occurrence of slight haemorrhage is a fortunate cir- 
cumstance, as it is generally followed by a decrease of the in- 
flammatory symptoms. If the discharge be profuse, means for 
repressing it should be adopted ; and of these, the application of 



BLENNORRHAGIA. 59 

ice-cold water to the perinaeum is one of the best ; — cold water 
may likewise be injected into the urethra. Or, what is better, 
and more conveniently done, pressure should be made with the 
thumb and finger upon the urethra deep in the perinaeum. If 
the haemorrhage be not arrested, draw the fingers gradually 
forward in the track of the urethra. The precise seat of the 
lesion, from whence the blood flows, will soon be detected ; and 
it will usually be found at the point of the urethra opposite the 
symphysis pubis. A compress should be placed upon the part, 
and secured by a roller around the loins and thighs. In three 
cases of profuse urethral haemorrhage, which I have met with, 
the accident occurred when the organ was in its greatest ten- 
sion, attended, in two instances, with chordee also. In one 
case, the patient lived at some distance from me. According to 
his own story, he bled a quart. He applied cloths dipped in 
cold water to the genitals ; but the bleeding, which took place in 
the dead of night, continued several hours. In the second indi- 
vidual, the laceration of the vessels occasioned a rapid flow of 
blood, which was arrested with ice-water and pressure upon the 
perinaeum. The third case occurred lately, and was on this 
wise. A young dandy, who had blennorrhagia " in floribus," 
took a fancy to have a ride in a cab on a bright summer's 
evening with a girl of the town. During the ride the girl got 
into his lap ; and while the parties were busily engaged in- 
mutual embraces, a vessel sprung a leak and bled profusely. 
The young man became alarmed. The cab drove up to the 
office of a physician. The patient alighted, and the cab went 
ahead with the female passenger. The physician, at whose door 
the bleeding lover was dropped, not being in, I was called. 
The youngster had on a pair of white trowsers. The blood was 
trickling down his legs. He exposed the genitals, and related 
the circumstances amid which the haemorrhage took place. The 
bleeding was staunched with cold applications and pressure, the 
patient lying on the floor for about an hour afterwards. 



CHAPTER m. 

GLEET. 

This is the blennorrhcea chronica of Dr. Good ; blennorrhoea 
luodes being, as we have seen, the name he gives to the clap 
or gonorrhoea. Gleet is a frequent sequel of an obstinate blen- 
norrhagia unsuccessfully treated or wholly neglected. The dis- 
charge is slight. Sometimes only a drop or two is noticed about 
the meatus urethral, in the morning. The orifice is smeared 
with a ropy, tenacious, serous or mucous fluid, partially dried 
perhaps, upon the lips, and slightly impeding the free exit of the 
stream of urine, when it first arrives at this part. Some patients 
have an oozing of matter, amounting to five or six drops in the 
twenty-four hours. . Sometimes several days will intervene and 
no discharge be noticed ; but if the patient indulge in any im- 
prudence in diet, severe exercise, sexual intercourse, or any- 
thing which tends to excite the organs, the gleet will very 
probably reappear. The most common seat of blennorrhoea is 
in the vicinity of the membranous or prostatic portion of the 
urethra ; the lesion, however, is sometimes situated in, or near, 
the fossa navicularis, as in acute urethritis. It is generally easy 
to determine when it is seated at the latter point ; for if it be, 
moderate squeezing of the glans penis will force the matter out 
at the orifice of the urethra, whereas this cannot be so readily 
done if the discharge proceeds from a portion of the canal 
farther back. Sometimes the locality may be ascertained by 
pressing the integument along the urethra. The patient will 
complain of being hurt when the diseased spot is reached. 

Occasionally, a preternatural redness and turgescence of the 
lips of the urethra remain after the discharge has ceased. This 
deviation from the healthy appearance is, of itself, an affair of 
little moment. It is, however, indicative of a more profound 

(60) 



GLEET. 61 

abnormal condition, which may still be lurking in the mucous 
lining of the canal, in Cowper's glands, or in the prostate, 
either or all of which parts may have been, at some period of 
the disease, concerned in the production of the morbid secretion, 
and may still be the seat of a subacute inflammation ; and so long 
as this continues, the patient is liable to a relapse from the most 
trivial excess or imprudence. He should, therefore, persevere 
in the treatment for some ten or fifteen days after the meatus 
has assumed its normal condition. Nor should he be allowed to 
indulge in the venereal act, until several weeks after the dis- 
cli9" e has stopped. Cases are on record In which the secretion 
oeen absent for a whole month, and then has been repro- 
duced by sexual intercourse with a perfectly healthy woman. 
Such facts are entitled to remembrance. They should make the 
surgeon cautions what answer he gives to the inquiry which is 
frequently made by the patient, " When may I venture to 
marry ? " The answer in some cases must be given under cir- 
cumstances involving no small responsibility. 

Some men, with an old gleet, suffer great mental distress in 
consequence of its presence, although it does not interfere with 
their physical health. A few months since, an intelligent but 
nervous man, from a neighboring village, was sent to me by his 
physician to be treated for gleet. It had existed about one year. 
The discharge consisted of a drop or two of mucus in the 
morning. No stricture or other irregularity of the urethral 
canal was found. The catheter slipped into the bladder at 
once ; virility was unimpaired. The patient had been reading 
an old medical book which fell in his way, and he became 
greatly alarmed, apprehending that the venereal complaint, in 
some form, might break out upon him at any moment unless his 
gleet were cured. A matter of business called him to Georgia ; 
but he dared not undertake the journey while his genitals were 
in such a critical state. He was put upon the use of the follow- 
ing : — 

R. Tinctura? Cantharidis, . . 

Olei Terebinthinae, aa, § j. 

Mucilaginis Acacia?, § ij. M. 

Dose. — One teaspoonful three times a day. 

6 



62 GONORRHCEA AND SYPHILIS. 

The following injection was also prescribed : — 

R. Acidi Tannici, t) j. 

Plumbi Acetatis, gr. viij. 

Aquae Fontanse, § viij. M. 

A syringeful to be injected three or four times in the twenty-four hours. 

The whole of the perineal integument was likewise made per- 
fectly raw with the compound tincture of iodine, and the patient 
was confined to his room. The gleet ceased on the sixth day, 
but the remedies were continued for two weeks longer in 
diminished force. The patient was encouraged to start on his 
journey. On reaching Philadelphia he fancied that he detected 
a relapse of his gleet, and forthwith returned to me. Nothing 
would appease him but a renewal of treatment, although I 
assured him there was no call for it. Meantime, as •no gleet 
appeared, his mind became tranquil, and he was convinced that 
he had no occasion to return as he did from Philadelphia. He 
once more commenced his Southern trip, which he completed 
successfully. 

I have examined with the microscope numerous specimens of 
true gleety matter. In most instances it consists of large, deli- 
cate, well-defined epithelial cells and free nuclei, which remain 
entire after the other portions of the morbid product are decom- 
posed and broken up into mere shreds and amorphous granules. 
In other samples I have found pus-globules, although seldom in 
abundance. If the individual indulge in any excess, and thus 
augment the local inflammatory action, a corresponding increase 
of pus-globules can be detected. 

It is not easy to say, pathologically, at what precise point in 
the progress of urethritis the inflammatory gonorrhoea ceases, 
and the gleet commences. Here we encounter a difficulty 
analogous to that which presents itself when we speak of the 
termination of an active inflammation in any other organ or 
membrane, and the commencement of a supervening subacute 
inflammation. We have no means of running a line of distinc- 
tion that shall be mathematically correct ; but for all practical 
purposes required in therapeutic surgery, our resources are 
sufficiently ample, and, for the most part, ultimately successful ; 
although it must be confessed that they are occasionally wholly 
inefficient. 



GLEET. 63 

Treatment of. Gleet. — Gleet .has been cured by a great 
contrariety of treatment. There is no one plan that can claim 
absolute supremacy over all others in all cases. The remedies 
appropriate for one constitution, may be prejudicial to another; 
and what may be suitable for a patient to-day, may be injurious 
to him to-morrow. Whatever course of treatment the surgeon 
decides to take, let him bear in mind that he is dealing with a 
urethritis — a mere modification of the same malady that was 
treated under the name of gonorrhoea or blennorrhagia. This 
is true, certainly, of the great majority of cases which we call 
gleet. In some few instances, the discharge is kept alive by 
something more than a subacute inflammation of the urethra. 
There may be hypertrophy of the prostate ; or inflammation of 
the vesiculse seminales, — or inflammation or irritation of the 
neck of the bladder ; or stricture in some portion of the urethra. 
All these contingences will suggest themselves to the considera- 
tion of the scientific practitioner ; nor will he leave unemployed 
any available means of arriving at a correct opinion in regard to 
these possible conditions before commencing the treatment of a 
case. An important point to be determined at this juncture, 
relates to the existence of stricture. The citheter or bougie 
will clear up all doubts upon this question. Patients very often 
apply to a surgeon to be cured of stricture when they have 
none. They have a gleet, — the sequence of a gonorrhoea that 
has been mismanaged by some knavish quack, who lias neither 
medical skill nor moral principle. He tells the man that his 
gleet is dependent on a dangerous stricture, which must be 
operated upon with the catheter or bougie every few days, or his 
urethra will close up so that he cannot make water ; and he 
promises to cure the poor fellow for so much — usually an enor- 
mous sum ; whereas, upon proper examination of the part, no 
stricture can be found.* 

The urethral lacunas are much more developed in some 
persons than in others ; and when the walls of these little 
recesses are in a state of congestion or hypertrophy, from pre- 

* " There is a class of scoundrels who live, not by curing strictures, but invent- 
ing them. Let an unhappy wretch fall into their hands, and if his urethra will 
admit a poker, they, will still persuade him he is strictured. The duration of his 
case will be in the compound ratio of the extent of his credulity, and the fulness 
of his pocket." — Henry J. Johnson. 



64 GONORRHOEA AND SYPHILIS. 

vious inflammation, they will naturally oppose the free passage 
of the instrument along the canal ; and unless the operator be 
somewhat familiar with the bougie, he may mistake this opposi- 
tion for stricture. Long standing blennorrhagia, in which the 
symptoms have been very severe, may produce the change in 
the lacunas here alluded to ; and the obstacle, which, when in 
this state, they must offer to the extremity of a bougie, may be 
misinterpreted ; and if the manipulator were to persist in his 
efforts to urge the instrument farther in, he might easily rend 
the parts — make a false passage — manufacture a pouch — or 
even create a stricture. 

Blisters in Gleet. — Of all local remedies, these stand at 
the head of the list for the cure of all cases not dependent on 
stricture or otherwise complicated. They may be applied along 
the whole length of the penis, except two or three lines towards 
the preputial orifice. As soon as vesication has taken place, the 
organ may be lubricated with equal parts of lime water and 
olive oil, or the benzoated zinc ointment, and wrapped in a linen 
rag. Of late I have used cantharidal collodion in preference to 
blistering cerate. The collodion may be applied by means of a 
camel's-hair pencil. After the evaporation of the ether, which 
takes place in a few seconds, the parts may be protected with 
linen rag. The vesicating substance should be applied at bed- 
time. If the surgeon propose to blister the perineal integument, 
he will find the collodion much more convenient than any other 
substance. It is better adapted to the uneven surface than 
plaster, does not stain the linen like tincture of iodine, and acts 
more powerfully and rapidly than the latter.* 

I have often cured a gleet with one application of the medi- 
cated collodion. The discharge does not usually disappear 
until the fifth or sixth day after vesication has been produced ; 
sometimes eight or ten days will intervene before it entirely 

* u If only pure gleet, sometimes mucous, sometimes purulent, be met with, it 
will, in almost every case, yield to a blister ; very rarely does it require a second. 
Blistering is, I may now safely say, the safest, quickest, and most efficacious 
remedy of all that have ever been proposed. Those who have had numbers of 
these cases under their hands, and felt the constant disappointment which the 
use of every other remedy brings with it, will soon appreciate its value. I have 
heard it condemned as a violent, painful, unpleasant remedy. I deny it." — ■ 
Milton in Med. Times and Gazette, 



GLEET. 65 

ceases. In a few instances a second application has been re- 
quired, but I have rarely found occasion for a third. Patients 
generally prefer to submit to the operation on Saturday evening. 
During the following day they are obliged to remain at rest ; 
sometimes for a longer period. 

There is still another region upon which large blisters can be 
applied in cases of gonorrhoea and gleet, and that is high up on 
the inner surface of the thighs. They should be about three 
inches by three, and be secured by a margin of adhesive plaster, 
and, as a matter of convenience, should be put on when the 
patient goes to bed at night, and be allowed to remain on until 
next morning. A blister on each thigh may be applied at the 
same time. The vesicated surfaces may be dressed with cold 
cream, the benzoated zinc ointment, or lint soaked in castor oil. 
Very likely the urethral discharge may be increased for twenty- 
four or forty-eight hours, and the patient will experience an 
inconvenient scalding on micturition, and it will be well for him 
to be provided with an antidote as in the following prescrip- 
tion : — 

R. Misturse Camphorse, § ij. 

Spiritus iEtheris Nitrici, § j. 

M. Mucilaginis Acacias, § ss. 

Dose. — Two teaspoonfuls every hour until four or five doses are taken, if 
necessary. A warm bath also, if the symptoms are urgent, of which there is 
very little probability. 

The final and speedy result of thus blistering the thighs, has, 
in some cases, proved entirely satisfactory. I have tried them 
and have succeeded ; — I have tried them and have failed. 

Injections in Gleet. — The number of these, as in gonor- 
rhoea, is well nigh legion. Some of them prove important allies 
to other remedial agencies ; some are nearly inert ; and some, 
absolutely mischievous. Injections should be weak at first, and 
always used cautiously. It is best to commence with two or 
three repetitions for three or four days, and let the patient 
report progress. If no ill results, the repetitions may be more 
frequent. The urethral canal should be kept as free as possible 
from all gleety secretion. Hence the benefit of weak injections 
often repeated, rather than to use more potent ones, which must 
6* 



QQ GONORRHOEA AND SYPHILIS. 

be employed less frequently, and even then may make the last 
state of the patient worse than the first. Frequent injections of 
ice-water are usually productive of beneficial effects. 

In refractory cases, where the deep portions of the canal are 
involved, advantage is sometimes realized from inserting into 
the urethra, to the depth of about four inches, a catheter having 
perforations in the sides, and pressing a drachm or two of the 
injection into the extremity of the catheter, by means of a small 
syringe. One of the best, as well as one of the cleanliest injec- 
tions, is nitric acid, diluted thus : — 

R. Acidi Nitrici, gtt. xx. 

Aquae Fontanse, § viij. M. 

Of this, a drachm may be injected every hour, or even oftener, 
if the patient choose. The caution, given above, need not be 
observed in regard to this preparation. Being quite weak, no 
injury would ensue were it to remain in constant contact with 
the lining membrane of the urethra. Its action is that of a 
tonic and astringent to the mucous tissue. Another injection, 
to which I am partial, is the French chloride of soda, where I 
am sure of procuring the genuine manufacture. I employ it, 
diluted in the proportion of one part of the solution to sixteen 
parts of rain water. It may be repeated ad libitum. The 
oxymuriate of mercury, — one grain to eight ounces of rose 
water, makes a valuable injection in many cases. The nitrate 
of strychnia has been employed with beneficial effects as an 
injection in gleet, not depending upon stricture, accompanied or 
not, by disease of the prostate gland. Nux vomica may be 
given internally at the same time. 

R. Strychnia?, gr. iv. 

Acidi Nitrici, gtt. viij. 

Aquae, § iv. M. 

Inject one drachm thrice daily, after micturition. 

JEt. Extracti Nucis Vomicae, gr. xij. 

Quiniae Sulphatis, 

Extracti Hyoscyami, aa 7 gr. xxiv. 

M. In pil. No. xxiv. divid. Two pills to be taken one hour before each 
meal.* 

* Vide Amer. Journal Medical Sciences, April, 1850, p. 542, 



GLEET. 6T 

The chloride of zinc makes a valuable injection in some cases 
of gleet and also in gonorrhoea. The usual formula which I 
have employed is : 

R. Zinci Chloridi, grs. vj. 

Aquae Rosarum, § vj. 

M. To be used twice in the twenty-four hours for a few days, after which 
more frequently, if no unpleasant effect is complained of by the patient. 

The acid nitrate of mercury (Hydrargyri Pernitratis Liquor), 
is the only remaining therapeutic agent which I shall present in 
this connection to the attention of the practitioner. For several 
years it has been employed by Mr. Childs, Surgeon to the 
Metropolitan Free Hospital, London, in cases of urethritis, and, 
as he states, with the most gratifying success. The strength of 
the injection employed is in the proportion of 

K:. Liquoris Hydrargyri Pernitratis, gtt. iij. 

Aquas Destillatae, § viij. M. 

Injection. — To be used once, twice, or thrice daily, as the patient can con- 
veniently bear. 

It is hardly worth while to continue an injection if it do not 
exert the desired action in the course of one week. The 
mucous membrane requires some other kind of stimulant. 

The Bougie. — Few cases, comparatively, present themselves 
in private practice, under circumstances demanding the use of 
this instrument. Now that confidence in the employment of 
blisters has recently been revived by Mr. Milton, who holds that 
all cases of gleet, not complicated with stricture, may be cured 
through the combined agency of repeated vesication of the 
penis and injections into the urethra, it is highly probable that 
the bougie will hereafter be in less frequent requisition than it 
has been hitherto. If a patient have stricture, the bougie will 
be needed. It may likewise be of service when a gleet is pro- 
tracted for a very long time in consequence of an irritable state 
of the neck of the bladder. There is still another class of 
patients, who may be benefited by the same mechanical means, 
when all other agencies have been exhausted ; for such cases, it 
is to be presumed, will still continue to occur, to the great 



68 GONORRHOEA AND SYPHILIS. 

annoyance of the most skilful surgeon ; and they will resist his 
best endeavors, until he avails himself of the bougie. Such 
cases, however, will, without doubt, be extremely rare. They 
include those individuals who have never had stricture ; who 
have no abnormal vesical irritability ; no chordee ; and little or 
no tenderness along the perineal region ; their condition has 
remained nearly the same for several months ; the parts endure 
without complaint, comparatively rude .handling, and seem 
almost callous to the ordinary influence of injections. And yet 
the judicious use of the simple bougie may restore the urethra 
to a sound condition, and put an end to the morbid secretion. 

In regard to the use of the bougie, surgeons prescribe some- 
what different directions. The instrument should be sufficiently 
voluminous to distend the urethra moderately, and nothing 
more. A bougie unmedicated should be introduced at first. 
It should extend some five or six inches into the canal, and be 
allowed to remain ten or fifteen minutes, according to the 
amount of irritation it creates. Its introduction, in some in- 
stances, may be repeated two or three times in a day ; in other 
cases, only once in two or three days. Patients manifest every 
degree of susceptibility as to their power to endure the presence 
of the bougie, some being able to bear it nearly all the time ; 
others cannot submit to its action, even for a few moments, a 
second time, so great is the suffering and inflammation which 
they experience. For persons in whom an incipient stricturo is 
detected the bougie should be used every third or fourth day ; 
and during the intervals an injection of tannic acid and sul- 
phate of zinc — one grain of each to the ounce of rain water — 
should be employed. 

The mucous membrane becomes thickened and softened in 
consequence of inflammation ; the tender walls of the canal 
may be easily lacerated, and consequent haemorrhage take 
place if the catheter or bougie be introduced in a rude or care- 
less manner. Sir Astley Cooper mentions a case of the kind, 
to which he was summoned by the physician who was guilty of 
this malpractice. The flow of blood was checked by pressing 
a roller upon the perinaeum. In a short time the haemorrhage 
returned. The man had been lounging before the fire, with a 
foot on each side of the chimney-piece ; and the warmth, 
coming thus in direct contact with the perinseum, brought on 



GLEET. 69 

a renewal of the bleeding. Sir Astley was again summoned, 
made an incision upon the part, and divided the artery of the 
bulb ; this operation succeeded, and the haemorrhage was per- 
manently subdued. 

In some cases of long-continued blennorrhagia, during which 
a variety of remedies have been applied directly to the urethra, 
it seems to lose its normal susceptibility ; and if, after a few 
trials with the simple bougie, no effect is perceptible, the instru- 
ment may be coated with some slightly stimulating ointment, 
thus : — 

R. Unguenti Hydrargyri, 1 part. 

Extracti Belladonna?, 2 parts. M. 

The bougie should be introduced cautiously ; and, on with- 
drawing it, the surgeon should give it a slight rotatory move- 
ment, which will cause an equal distribution of the ointment 
to the whole surface of the canal. The employment of the 
instrument thus medicated gives considerable pain, and excites 
inflammation ; and usually an increase of discharge is noticed 
for a few days, after which it frequently entirely ceases. But 
if this do not happen, a second trial with the instrument may 
be made in ten or twelve days from the first. An ointment of 
the nitrate of silver — one grain to the drachm — is sometimes 
efficacious when used as directed above for the mercurial un- 
guent. The unguentum hydrargyri nitratis, in the proportion 
of one drachm to an ounce of pure olive-oil, is likewise a very 
suitable application under the circumstances here supposed. 
Sometimes the oil of turpentine answers a better purpose than 
any other substance for lubricating the bougie. 

CONSTITUTIONAL TREATMENT OF GLEET. 

Internal remedies alone seldom result in the cure of gleet. 
In nine cases out of ten the patient is doomed to meet with 
disappointment, after having run the gauntlet of all kinds and 
forms of specifics (so called) addressed to the stomach. Tonics 
are generally useful ; they may be given with saline aperients 
or alterative mercurial medicines, or in combination with reme- 
dies reputed to exert a specific influence upon the genital sys- 
tem. Little will ever be gained by any process of starvation. 



70 GONORRHCEA AND SYPHILIS. 

A plain but substantial diet should be allowed, of which lean 
meats should constitute a part. The subjoined formulae are 
among the best that can be employed. If they fail to arrest 
the morbid secretion, it will hardly be worth while to waste 
time in experimenting with other preparations for internal 
exhibition. A far more hopeful procedure will be to resort 
to blistering, as already sufficiently recommended. 

ft. Copaibae, § ss. 

Tincturae Cantharidis, § ij. 

" Ferri Sesquichloridi, §j. M. 

Dose. — Thirty drops three times a day in a gill of sweetened water. 

ft. Tincturae Cantharidis, §j. 

Quiniae Sulphatis, 5 ss. 

Tincturae Ferri Sesquichloridi, 5 ij. 

Acidi Sulphurici Diluti ? 5 ss. 

Aquae, § viij. M. 

Dose. — One ounce three times a day in an equal quantity of cold water. 

When there is a thickened and uneven condition of the ure- 
thra, the annexed formula will be found appropriate : — 

ft. Hydrargyri Biniodidi, gr. iij. 

Potassii Iodidi, 5 iss. 

Spiritus Rectificati, § ss. 

Syrupi Aurantii, § iiss. M. 

Dose. — Thirty drops three times a day. 

Good results are often realized from the use of the iodide of 
potassium in conjunction with iodine. Such a combination, 
containing both tonic and alterative qualities, is especially indi- 
cated in the constitutional treatment of those who betray a 
scrofulous diathesis : — 

ft. Potassii Iodidi. 3 iij- 

Iodinii, gr. j. 

Aquae Destillatae, § vij. M. 

Dose. — One drachm three times a day. 

Ferruginous preparations are likewise valuable for patients 
who have become pale, emaciated, nervous, and apathetic. The 



GLEET. 71 

potassio-tartrate of iron, or the citrate of iron, should be pre- 
scribed. in pretty liberal quantities for several weeks. Mr. Dick 
states that a combination of the carbonate of iron with ergot 
has in his practice rendered good service. In two cases, where 
all other remedies had failed, the patients obtained the desired 
benefit from the following prescription : — 

K. Secalis Cornuti, . 5 iss. 

Ferri Carbonatis, 5 ij- 

Pulveris Vanillae, 

" Camphorae, aa, gr. vj. 

Ft. pulv. Div. in partes No. xxiv. One powder morning and evening. 

The oil of turpentine, as a constitutional remedy in obstinate 
cases of gonorrhoea and gleet, is entitled to favorable considera- 
tion. Its pungent and nauseous taste constitutes a serious 
objection to its employment, and hence it is rarely resorted 
to until other less disagreeable remedies have been tried and 
have failed. I have never ordered it in the acute form of 
abnormal urethral discharges, but in chronic cases, which have 
resisted other remedies, have prescribed it with advantage. It 
should be combined with an anodyne, and administered as an 
emulsion. The annexed formula is as convenient as any : — 

R. Morphise Sulphatis, gr. j. 

Sacchari, 3iij. 

Misturae Camphorae, 

Mucilaginis Acacias, aa, § ij. 

Olei Terebinthinae, 3 ij- M. 

Dose. — Two drachms three times a day. 

Some patients, who have had urethritis for a long time, will 
complain, even after the morbid secretion has vanished, that 
they never know when they have done making water ; that is, 
they will tell you that, after they think the process is finished 
and the bladder empty, they are troubled for a moment or two 
with a dripping from the meatus, which makes them very 
uncomfortable. They can neither expel the last few drops of 
urine, nor yet retain it. In these respects their condition is not 
unlike that of some very aged men. The introduction of the 
bougie or catheter once or twice every twenty-four hours, for a 
few days, will generally remove this trouble. 



CHAPTER IV. 

BALANITIS. 

The word balanitis, as employed by syphilographers of the 
present day, signifies inflammation of the surface of the glans 
penis, the mucous membrane of the prepuce, the glandulse 
odoriferae, and the follicles that surround the corona. The dis- 
ease thus located, is also called balano-preputial blennorrhagia ; 
bastard chaude-pisse balanite by the French ; external blennor- 
rhagia ; spurious or false gonorrhoea. The inflammation is 
attended with more or less muco-purulent discharge, with or 
without superficial excoriations. If the disease be confined to 
the prepuce, it is called posthitis. But, as in most cases, all the 
tissues just named are involved, I shall employ the term bala- 
nitis as being sufficiently suggestive of the seat of the complaint. 
The liability of men to this disorder, depends in some degree 
upon the amount of preputial integument, with which the parts 
are naturally endowed ; and in this particular very great differ- 
ences are found. It is somewhat amusing to compare the opin- 
ions expressed by different writers in regard to this appendage. 
One says, " It has been a question with some philosophers of the 
Monboddo school, whether the prepuce is not a piece of superero- 
gation. It may have its uses in a state of nature, where it may 
defend the sensitive glans, and serve the purpose of ' sheath' in 
animals. But we are not likely to return to fig leaves, and I 
think I may take it upon myself to affirm, that at the present 
day and with our customs, the less we have of it the better. " * 
The prepuce, says Ricord, " is an appendix to the genital 
organs, the use and object of which I could never divine ; in 
place of being of use, it leads to a great deal of inconvenience, 
and the Jews have done well in circumcising their children, as 
it renders them free from one of the ills of humanity. The 

* Henry J. Johnson. 
(72) 



BALANITIS. 73 

prepuce is a superficial piece of skin and mucous membrane, 
which serves no other purpose than acting as reservoir for the 
collection of dirt, particularly when individuals are inattentive 
to cleanliness." In some men the prepuce is of remarkable 
brevity — hardly sufficient to conceal any portion of the glans, 
which, with them, always remains in nearly the same condition 
as if circumcision had been performed. 

The glandulae odoriferge, with their short excretory ducts, 
situated behind the glans, are disseminated much more plenti- 
fully in some men than in others ; varying, numerically, from 
ten to one hundred ; and while they are designed by nature to 
perform an important emunctory function analogous to that of 
the sudoriferous apparatus of the skin, they are at the same 
time subservient to the protection and healthy condition of. the 
parts in the immediate neighborhood, upon the surface of which 
they constantly pour out an oily, lubricating fluid. But, if this 
oily material be allowed to accumulate, and to become partially 
concrete, it may, and frequently does, prove a source of irri- 
tation and inflammation. It is scarcely necessary to remark 
that this accumulation is much more rapid and difficult of pre- 
vention if the glans be invested by a preter-naturally elongated 
prepuce, than is the case where the glans is naked, or covered 
by a foreskin of normal length, and easy of retraction. I once 
knew a young medical student who had a redundancy of prepu- 
tial membrane. After having been more or less annoyed for 
some weeks by a sensation of heat, itching, smarting, and pains 
about the head of the penis and the inner prepuce, he one 
morning noticed at the orifice of the latter, an opaque, semi- 
fluid substance, which proceeded, as he thought, from urethral 
gonorrhoea. He was, at the time, trying his skill as interne du 
service, or dresser to another young man, who, in addition to an 
acute blennorrhagia, had two or three ill-conditioned sores upon 
the prepuce. These received frequent attentions from the 
student, who, not fully indoctrinated into the laws of contagion, 
imagined that his own Rouble was derived from this patient, as 
he had not been otherwise exposed. Upon retracting the pre- 
puce, a large quantity of thick, sebaceous matter gushed out. 
This filth was removed with warm water, and the glans was 
found to be inflamed and denuded of its epithelium in several 
places, and aphthous patches here and there upon it. But 
7 



74 GONORRHOEA AND SYPHILIS. 

there was no urethral discharge. The student, at once satisfied 
as to the cause and source of his complaint, was not a little 
mortified, He listened to a few suggestions relative to personal 
cleanliness ; and with the use of weak lead-water, found himself 
well at the end of a week. Instances like this occasionally 
present themselves ; and when the patient is told that his 
difficulty is attributable to his own carelessness, he is apt to 
manifest surprise, mingled with shame and joy, at the dis- 
covery. 

The existence of the prepuce is the principal predisposing 
cause of balanitis. Vidal, however, mentions that he once ob- 
served it in a man on whom he operated for phymosis by cir- 
cumcision. The exciting causes of the complaint are numerous. 
Impure sexual congress is at the head of the list. The men- 
strual fluid, leucorrhoea, masturbation, and inattention to clean- 
liness, will occasionally produce it. If it be the result of 
intercourse with an infected female, the symptoms generally 
begin to show themselves in a day or two after exposure. The 
period of incubation is shorter than in cases of urethral blen- 
norrhagia. The first warning of the trouble is a slight tingling 
or smarting sensation in the prepuce or glans. Anon, the pre- 
puce becomes very tender and oedematous ; and if it be drawn 
back upon the glans, the latter will exhibit inflammatory action 
more or less intense ; and at a later period, if nothing be done 
to check the morbid process, a discharge of puriform fluid will 
take place from the glans, — near the frasnum. There is scald- 
ing in micturition. If the trouble arise entirely from unclean- 
liness, it is more gradual in its development; the symptoms 
declaring themselves more and more manifestly as the acrid 
sebaceous product is allowed to accumulate. The muco-puru- 
lent matter, mingled with the natural secretion from the parts, 
is sometimes very abundant, and if the preputial orifice be nar- 
row, and the escape of the fluid obstructed, will sometimes give 
rise to a sort of abscess ; and it may be necessary to puncture 
the prepuce for the purpose of evacuating it. If phymosis 
complicate the balanitis, and the case be neglected, or injudi- 
ciously conducted, sloughing of the prepuce may take place, 
and the glans be seized with severe inflammation ; and this 
morbid action may extend to the lymphatics of the penis and 
of the inguinal region. 



BALANITIS. 75 

Treatment of Balanitis. — Simple balanitis is quickly cured. 
The patient should be directed to draw back the prepuce so as 
entirely to expose the glans, as well as the mucous surface of 
the prepuce, which should be bathed in tepid water, and thor- 
oughly cleansed of all sebaceous and puriform deposit. A fair 
view can now be had of the parts implicated. The surgeon will 
find slight abrasions and small patches of aphthae. For the 
cure of these, one of the best topical applications is the fol- 
lowing : — 

R. Liquoris Sodse Chlorinatse, § ss. 

Aquae Fontanse, § vij. M. 

Small bits of English lint to be saturated with the solu- 
tion, and laid upon the glans ; and the prepuce may then be 
brought forward. The penis should be covered with a light wet 
rag. The solution should be re-applied three or four times a 
day. In all ordinary cases this simple local medication will 
restore the parts to a healthy state in a very few days. An es- 
sential item is to keep the surfaces from coming in contact. In 
some cases a piece of soft, dry lint, snugly placed in the furrow 
behind the corona, will speedily remove all trouble ; and proper 
attention to cleanliness will prevent its recurrence. If the 
erosion be considerable, and the puriform exudation copious, an 
astringent lotion may be appropriate, thus : — 

M. Zinci Sulphatis, gr. ij. 

Acidi Tannici, . . . gr. iv. 

Glycerinae, 3 ij- 

Aquae Fontanse, § iv. M. 

Apply with lint. 

Simple lime-water frequently answers all the purposes, and 
effects a cure rapidly. In some cases I have tried the black 
wash, but its action has not proved salutary. It is too 
stimulating and on that account will rarely suit, but will 
rather aggravate, the morbid condition of the parts. The 
introduction of a crayon of nitrate of silver between the glans 
and the prepuce in severe cases, is a practice adopted by some 
surgeons. If the prepuce can be retracted, it would seem that 
such application is uncalled for; and if, on the contrary, there 



76 GONORRHOEA AND SYPHILIS. 

be phymosis, the proper application of such a caustic is a matter 
of no easy performance. Besides it might very likely augment 
the inflammation. 

Phymosis. — If there be a close phymosis, so that no expo- 
sure of the glans can be effected, the whole mucous surface 
may be irrigated and thoroughly cleansed with tepid water 
many times in the course of the day, by means of a small 
syringe, which should be inserted as far up the preputial 
opening as possible. All extraneous deposit will thus very 
soon be expelled from its hiding place, and the inflamma- 
tion and irritation, occasioned by the presence of this deposit, 
be rapidly diminished. Sometimes a few drops of Goulard's 
extract of lead can advantageously be added to the water used 
as an injection. The patient should live abstemiously and keep 
quiet. 

After the symptoms have abated, the phymosis will some- 
times yield, and a normal condition of the parts be secured by 
introducing a sponge-tent and gradually dilating the opening. 
All the measures above suggested sometimes prove merely 
palliative ; they do not accomplish a radical cure, especially 
if a congenital or persistent phymosis exists. The balanitis 
becomes chronic ; and the severity of the symptoms can be 
kept in abeyance only by the steady application of remedies 
for a very long time, unless the patient submit to a surgical 
operation for the cure of his phymosis. And this is by far 
the wisest course. The glans and prepuce are both inflamed 
and in a turgid state ; and while this is the case, a mutual 
fretting of the parts will not only be kept up, but the injury 
will be cumulative. The cedematous prepuce cannot slacken 
and expand so as to make room for the glans ; while the 
latter, in turn, has a tendency to swell more and more, and 
consequently to exert an increased pressure against the inner 
surface of the former. Under such circumstances the best 
mode of treatment is sufficiently plain to the judgment of 
the surgeon. 

Division of the foreskin will be expedient ; or, if this appen- 
dage be of extraordinary length, circumcision is to be pre- 
ferred. In all ordinary cases, Sir Astley Cooper and Mr. 
Johnson advise that it be divided along the mesial line. The 



BALANITIS. 77 

latter surgeon says : " Division of the foreskin is very suc- 
cessful ; and even when it is considerably elongated, the flaps 
of integument that depend on either side are ultimately so 
absorbed as to occasion little unsightliness, if any. I can 
scarcely dwell too earnestly on the advantages of this opera- 
tion in cases of chroniG balanitis." Sir Astley is equally in 
favor of this operation. The method of procedure is this : 
Insert a director into the preputial cavity, and let it slide along 
the dorsum of the glans until it has reached the point of reflec- 
tion of the prepuce behind the corona. Move the point of the 
director about so as to be sure that it is where you want it, 
and that it has not entered the urethra. Then tilt up the 
point of the instrument. Next, run a sharp pointed bistoury 
along the groove of the director, and transfix the prepuce at 
the point where that instrument projects under the skin, and 
complete the division by cutting out and bringing the bistoury 
towards you. Some surgeons prefer to divide the prepuce at 
its lowest aspect by the side of the fraenum, and assign as a 
reason that less deformity and unseemliness result, than is the 
case if the operation be performed on the superior aspect. 
When the prepuce is redundant in front of the glans, it may 
be drawn forward and cut with a knife or pair of scissors at 
a stroke. The mucous membrane may still be too tight ; in 
which case it can be slit up at two or three points, and the ends 
of the flaps be secured by suture to the outer integument. 
There is still another, and a very neat operation for the relief 
of phymosis, even when most complete. The instrument em- 
ployed is a pair of very delicate straight scissors, of which one 
of the blades is terminated by a little button, like a probe- 
pointed bistoury. The surgeon glides the point of this blade 
between the glans and the prepuce, while the sharp pointed 
blade is thrust between the inner membrane and external 
skin beyond the stricture. The mucous membrane now sep- 
arates the two blades, and by closing these, this membrane is 
divided to the distance requisite to allow the prepuce to be 
drawn back, and thus relieve the phymosis. The edges of 
the wound spontaneously separate, and cicatrization follows. 
The operation leaves no deformity. It is called Cullerier's oper- 
ation ; and has been performed at the Pennsylvania Hospital 
7* 



78 GONORRHOEA AND SYPHILIS. 

for many years with success.* Either of these operations may 
be resorted to with a view to give facilities for carrying out 
other measures of treatment. If no congenital or permanent 
phymosis existed before the disease, there will be less urgency 
for the operation ; so likewise if chancres exist within the 
preputial cavity, it will be best not to perform the operation 
hastily, because the wounds might be inoculated with the chan- 
crous matter. Should the symptoms be urgent, and there be 
danger of perforation of the prepuce, or of gangrene, then the 
operation will be demanded even at some risk of inoculating 
the wound. The danger here alluded to will be essentially 
diminished, if a strong solution of chloride of soda be applied 
to the chancre, or if nitric acid be employed as an escharotic. 
We have the authority of Mr. Cooper for dividing the prepuce, 
even when the worst kinds of ulcerations are present, either 
upon the glans or prepuce. He was accustomed to operate 
in this manner under such circumstances, and he assures us 
that he never*saw, in a single instance, any ill consequences, 
— never knew any unfavorable ulcerations arise in the edges 
of the wound. On the contrary, the sloughing chancre or 
phagedenic ulceration is more likely to assume a healthy 
condition after the prepuce is divided ; and all the parts pro- 
ceed more favorably from the moment they are thus liberated, 
and nature is allowed to come to the rescue. 

Circumcision. — In permanent or congenital phymosis, this 
operation may be required ; and as it can, like all other surgical 
operations, be performed without pain, it is a procedure vastly 
less objectionable than it was formerly. Its results are more 
beneficial and complete than mere division of the prepuce. 
No deformity is left — a fact of no little concernment to the 
owner, — and, what is still more important to him is, he is in 
no danger of ever again being troubled with phymosis or 
paraphymosis, nor yet, probably, with balanitis. Several 
methods, which vary slightly, are practised by surgeons in 
the removal of the prepuce. Mr. Milton's plan is simple and 
is as good as any. It gives a neat appearance to the parts. 
His mode of procedure is — to slit up the skin and mucous 
membrane as far as the reflection of the latter, and then cut 

* See Miller's Surgery, edited by Sargent, p. 587. 



BALANITIS. 79 

away the frssnum as far as practicable. The constricted part, 
which is near the edge, is removed in a circle, and the bleed- 
ing being stopped, the skin and the mucous membrane are 
brought together by stitches, and covered with collodion. 

Paraphymosis. — When there is great constriction and nar- 
rowing of the prepuce from inflammation, it frequently hap- 
pens, that if this covering be pulled back behind the glans, it 
cannot again be brought forward to its normal position over 
this portion of the organ. It remains retracted, forming a 
band or ligature around the part just behind the corona, and 
occasioning strangulation analogous to that which takes place 
in intestinal hernia. This morbid condition of the penis is 
known in surgical language as paraphymosis. 

Infiltration into the integument takes place rapidly on either 
side of the stricture ; and the glans likewise is distended with 
blood, and painful. There seems to be no power in the sys- 
tem to control the local inflammatory process that has been 
awakened; and which, if not checked by judicious manage- 
ment, will very likely result in a partial or total destruction 
of some of the tissues. Nature's method of relief, which the 
medical attendant sometimes witnesses, consists in a sloughing 
of the integument, including a portion of the ligature that pro- 
duces the constriction. The surgeon, however, if called sea- 
sonably, and if qualified for the duties of the occasion, will 
prevent this work of destruction. Let us consider the best 
means of doing this. A simply antiphlogistic treatment will 
sometimes bring immediate relief, as in the following 

Case. — August 13, 1856. — Was called early in the morn- 
ing to see a stout, fat, full-blooded young man of dissipated 
habits. He was suffering from a paraphymosis, which had pro- 
gressed gradually for five days. The parts were swollen, hot, 
livid, and painful. The patient had kept his bed most of the 
time for eight-and-forty hours. On the day previous to my 
visit, his bowels had been twice moved by a dose of castor 
oil. Tongue coated, thirst considerable, pulse full, — ninety 
per minute. Ordered a large dose of sulphate of magnesia, 
cooling drinks, warm water to genitals, and a warm bath in the 
evening ; patient to remain immersed until he became faint. 



80 GONORRHOEA AND SYPHILIS, 

Warm fomentations during night. Next morning preputial 
tumefaction and swelling of glans nearly gone, and paraphymo- 
sis much relieved, although the foreskin could not be brought 
over the glans ; general condition of the patient improved. 
Continued hot fomentations, and in the evening repeated the warm 
bath. On the third day, the prepuce advanced over the glans 
sufficiently, and the. parts soon regained their normal state. 

If the patient be seen before the parts are " in extremis," the 
surgeon may attempt reduction of the constriction by pressing 
the glans steadily for fifteen or twenty minutes. If it be con- 
siderably diminished by the procedure, it may be pushed back- 
ward with the thumb and forefinger of one hand, while with 
the fingers of the other, an attempt is made to bring forward 
the prepuce. This manipulation is often successful. Should it 
fail, compression may be made by means of a delicate, narrow 
linen bandage, bound round the parts by commencing at the 
end of the penis and proceeding backwards, until a uniform 
pressure is brought to bear upon them. An old linen handker- 
chief furnishes a good material for the bandage. It should be 
torn into strips half an inch wide, and be applied so as to act 
equally on the parts. The degree of pressure should be as 
great as can be borne conveniently, and no more. Each suc- 
cessive turn of bandage should overlie the previous one by about 
one-half its width. If the bandage exert too much pressure, 
the patient can easily slacken it. This is a more sure and 
effectual plan than the taxis, and no mode of pressure can be 
more safe. M. Seutin, of Berlin, proposes the use of forceps, 
with spoon-like ends, which will embrace the glans, and produce 
compression more uniformly than can be done otherwise. The 
application of, and squeezing with, such a hard substance, upon 
the head of the penis, under such circumstances, will rarely be 
followed by successful results. If neither the taxis nor com- 
pression with bandages will overcome the difficulty, it is not at 
all probable that any instrumental force will answer any good 
purpose ; and the surgeon will scarcely find his account in 
wasting any more time in this manner. He should proceed at 
once to divide the stricture with a sharp-pointed bistoury. For 
this purpose he should seek the deepest portions of integument. 
If adhesions exist between the skin and the shaft of the penis, 
in consequence of plastic infiltration, they may require to be 



BALANITIS. 



81 



broken up ; or free incisions may be made at different points, 
if necessary, in order to secure still greater relief. 

Sometimes the prepuce remains irreducible for a few days 
after the stricture is relieved. Be this as it may, no rude 
manipulation should be practised for the purpose of bringing 
things to a natural condition. As soon as the inflammation has 
subsided, the proper co-aptation will take place, and the patient 
may be told quietly to await this result. 



CHAPTER Y. 

ORCHITIS. 

At the present day, practitioners make no delay in curing a 
gonorrhoea as soon as possible, by the most efficient means ; for 
experience has abundantly demonstrated that the morbid condi- 
tion, erroneously termed hernia humoralis, orchitis, and swelled 
testicle, is not occasioned by the ordinary use of balsam of copaiba 
or the powder of cubebs, which are regarded almost in the light 
of specifics in arresting the urethral discharge. Mr. Curling, 
than whom no higher authority on this subject can be cited, is 
accustomed to prescribe these remedies separately and con- 
jointly, in all stages of blennorrhagia ; and he has never found 
patients, thus treated, more liable to be attacked with orchitis 
than those who are treated differently. The same testimony 
may be gathered from the daily observations of medical men 
generally, who are constantly prescribing with impunity the 
remedial agents here spoken of. 

In regard to the agency of injections, in giving rise to or- 
chitis, it may be said that, if used with ordinary prudence, they 
do not produce it. If those of high strength be employed, and 
too frequently, they may induce this mischief. But enlarge- 
ment of the testicle most commonly arises in those cases of 
gonorrhoea which pass into a chronic state, particularly when 
the prostatic portion of the urethra is affected. Cases of this 
sort occur generally between the fourth and fifth week from 
the commencement of the discharge. They may be manufac- 
tured by the introduction and unskilful manceuvering of the 
catheter, or be induced by violent exercise, excessive stimula- 
tion, or other imprudences, calculated to augment the existing 
inflammation of the urethra, and excite a morbid action in the 
vesicular seminales and vas deferens, until it reaches the epidid- 
ymis ; or it may be generated in virtue of what physiologists 
call the common law of sympathy, the intervening parts not 

(82) 



ORCHITIS. 83 

being involved in disease. The action of a similar law is seen 
in cases of hernia humoralis, occasionally developed in connec- 
tion with mumps. While the urethra is the seat of a blennor- 
rhagic discharge, the other portions of the genito-urinary appa- 
ratus are easily brought into a diseased state also ; and among 
the accidents which attend this condition of the canal, orchitis 
is perhaps the most frequent. 

The testicles are connected by continuity of tissue with the 
mucous lining of the urethra, through the medium of the vasa 
deferentia ; and when inflammation has reached that part of 
the urethra in which these minute, intermediate canals termi- 
nate, it readily enough finds its way into them, and rapidly 
pursues its march, until it arrives at the convolutions of the 
epididymis, where its further progress is usually arrested. 
This appendix of the testis receives and retains the principal 
force of the morbid action, and thus serves as a wall of protec- 
tion to the parenchyma of the gland itself. Sometimes the 
enemy overleaps this barrier, and attacks the testis proper. In 
all cases there is a general and sudden swelling, — a swelling 
of the testicle, as we term it, — but this enlargement is pro- 
duced by the presence of lymph and serum within the tunica 
vaginalis. The epididymis is, after all, the chief seat of the 
disease in most instances. The old theory of metastasis, or 
the sudden translation of the inflammation from the urethra to 
the testicle, is not entitled to much favor. It is extremely 
questionable whether any thing of the kind ever takes place in 
gonorrheal orchitis. The inflammation, in a majority of sub- 
jects, may be traced advancing along the vas deferens to the 
epididymis ; or the morbid action may seize upon the latter 
without involving the vas deferens. This is what E-icord de- 
nominates sympathetic or vicarious inflammation. In nearly 
all cases of orchitis, the pain and urethral discharge diminish 
very considerably, especially during the early stage of the tes- 
ticular affection. 

When orchitis attacks young men who are troubled with 
blennorrhagia, the morbid action is more apt to reach the body 
or glandular structure of the testis, than it is in older men. 
These cases Vidal designates as parenchymatous orchitis. The 
swelling is comparatively moderate ; there is no serious effusion 
into the cavity of the tunica vaginalis, and the gland is drawn 



84 GONORRHOEA AM) SYPHILIS. 

upward towards the abdomen. This variety is attended with 
great pain ; and the symptoms are all much more severe and 
dangerous than those which accompany other forms of orchitis. 
The variety of orchitis, in which the vaginal tunic becomes 
rapidly distended with the exudation, is also very painful ; where 
the inflammation preponderates in the epididymis the suffering 
is much less. 

In .thirteen hundred and forty-two cases reported by Pro- 
fessor Sigmund, the seat of the disease is thus distinguished : 
the epididymis alone, sixty-one; the epididymis and cord, one 
hundred and eight ; epididymis and tunica vaginalis, eight 
hundred and fifty-six ; all the three parts, three hundred and 
seventeen. The testis itself, in more than half of these cases, 
was but a little enlarged. Of the number here cited, the 
left side alone was affected in two thirds, — the right in one 
third of the whole.* Yidal coincides with Sigmund that the 
left side is more frequently affected than the right ; it is on the 
left side also, he says, that the accident first appears when both 
testicles are attacked. The observations of Curling, Johnson, 
and others, indicate that the right testicle is the one most 
frequently involved. From the above evidence it is manifest 
that no great difference obtains as to the direction which nature 
takes, — the right or left. 

Symptoms op Orchitis. — The attack commences with a 
sense of increased weight in the testis, with a dull pain along 
the course of the spermatic cord, in the perinaeum, in the groin, 
and in the lumbar region. In a few hours the epididymis be- 
comes swollen at the lower portion, or tail, as it is called, — is 
hard, knotty, and tender to the touch ; the patient can scarcely 
tolerate any covering upon that side of the scrotum, or bear 
to have it come in contact with the thigh. He feels most com- 
fortable when he holds it in his hand. In two or three days, 
if not arrested, the inflammation reaches the tunica vaginalis*; 
and the general tumefaction, which preserves the natural, oval 
contour of the testicle, increases to the size of a hen's egg. 
The pain, which in the beginning was of a dull, aching de- 
scription, soon becomes more absolute, especially when the 
patient attempts to assume the erect posture. There is great 

* British and Foreign Med. Chir. Review, Oct. 1856. 



ORCHITIS. 85 

irritation in the bladder, and a constant desire to urinate. The 
distress about the loins, hips, and scrotum is sometimes excru- 
ciating. As the disease advances to its culmination, the sur- 
face of the scrotum, which invests the gland, participates in the 
inflammation, becomes red, hot, thickened, and ©edematous. 
Generally, the constitutional disturbance is not severe ; occa- 
sionally, it assumes a very serious character. Sometimes the 
patient suffers from extreme nausea, and perhaps vomits freely ; 
the tongue is coated ; there is great thirst; quick pulse; and 
all the symptoms maintain their activity for eight or ten days, 
by which time they are usually inclined to yield. The blen- 
norrhagia diminishes or wholly subsides for the time being ; and 
when the order of events is reversed in regard to the orchitis, 
— that is, when the symptoms begin to be less severe, and con- 
valescence from the scrotal trouble is fairly commenced, — the 
gonorrhoea generally reappears. Now and then the urethral 
flux is not affected in any way by the swollen condition of the 
testicle, even where no remedies have been used, and where the 
swelling has gone on increasing to the size of the fist ; and what 
is still more singular, instances have been known where the 
testicles have swollen and yet the discharge has become more 
profuse than before. 

In some feeble constitutions, the symptoms are moderate in 
degree, slow of development, and long in duration. Such 
cases are less easy of management than those in which an in- 
tensity of symptoms prevails. A trivial circumstance, such as 
carelessness on the part of the patient, or deviation from the 
prescribed line of treatment, will be sufficient to interrupt his 
progress towards a cure, and, perhaps, will provoke an unfortu- 
nate relapse. In some such way the malady may be trans- 
formed into a chronic orchitis or epididymitis, which may harass 
the patient more or less for many months, or even years. I once 
had a case of this kind in a married man living in the country. 
He was of a scrofulous diathesis, and every few months, on 
slight exposure, was tormented with swollen testicle for more 
than a dozen years after his recovery from an old, neglected 
gonorrhoea*. 

Treatment of Orchitis. — The modern treatment of blen- 
norrhagia has doubtless caused a diminution in the frequency of 
8 



86 GONOKRHCEA AND SYPHILIS. 

inflammation of the testicle, in this country at least, although, 
judging from the accounts that come to us in the medical 
journals from the other side of the Atlantic, such would not 
seem to be the fact in relation to the European population.* 
Any apparent immunity from this accident among our people, 
compared with its frequency among transatlantic subjects, must 
be ascribed, if real, not to superiority of treatment, for that we 
do not claim; but rather to the more provident and careful 
habits which characterize the ordinary classes of our citizens. 
These remarks involve no contradiction ; nor, I fancy, do they 
really traduce " our distant neighbors." 

The history of the symptoms, progress, and termination of 
orchitis, as it has been studied within the last few years, and 
as its real character now stands unfolded in the writings of such 
men as Astley Cooper, Curling, Velpeau, Brodio, and others, 
shows it to possess the attributes of a truly sthenic disease, and 
to be rapidly aggressive in its tendency. The clinical experi- 
ence of every practical physician and surgeon, at all familiar 
with the complaint, will bear witness to this truth. 

If the patient has the discretion to consult his medical ad- 
viser as soon as the symptoms that foreshadow the approach of 
orchitis begin to declare themselves, the testicle and its imme- 
diate dependences can frequently be rescued from the impend- 
ing danger. But in many instances, the man pays but little 
regard to the first sensations of uneasiness along the perinasum, 
the iliac fossa, and across the inferior portion of the spinal 
column. These symptoms continue for a day and a night, 
perhaps, when to his surprise, and while engaged in his usual 
pursuits, a sudden increase in their severity is experienced ; his 
gonorrhoea ceases ; a sharp pain, with swelling in -the posterior 
part of the scrotum, and other abnormal phenomena already 
specified, arouse his fears. He takes to his room, and the physi- 
cian is summoned. The individual being in the condition here 
supposed, should be directed to go to bed and lie on his back. 
A cushion of cotton and an old soft napkin should be so 
arranged between the thighs as to support the scrotum, and be 
gently tucked up against it, so that no dragging force can be 

* " Whatever may be the success attendant upon the treatment of gonor- 
rhoea in recent times, the number of cases of epididymitis does not seem to 
diminish." — British and Foreign Med. Chir. Review. 



ORCHITIS. 8T 

exerted upon the cord. The proper position of the parts being 
well secured, they are to be kept wet with cloths dipped in 
cold water. In two or three hours, ice may be added to the 
water. The patient will tolerate this degree of cold now, much 
better than he would at first. It is not exactly prudent to com- 
mence with ice-water. It is safer, as well as more comfortable 
to the person, to reduce the temperature gradually. The appli- 
cation may be continued without intermission, so long as it 
gives relief. A brisk cathartic should be prescribed ; low diet, 
as orange-ade, rice-water, bread-and-toast-water, or tea, and the 
like, for nourishment. It is hardly necessary to say that all 
stimulants should be forbidden. These measures, adopted 
early, will be likely to check the further progress of inflamma- 
tory action. They constitute, at any rate, the most judicious 
antiphlogistic treatment that can be instituted. They are to be 
persevered in with greater or less energy, according to the 
severity of the case and the constitution of the patient. If the 
symptoms continue to increase, ten or fifteen leeches should be 
applied to the peringeum, over the course of the inguinal canal 
or upon the dartos. and the flow of blood should be promoted 
by the application of warm water. It is seldom necessary to 
resort to venesection, not even by opening any of the scrotal 
veins. The latter operation would not be free from danger. It 
might expose to phlebitis. Instances of the kind are on record. 
After a sufficient quantity of blood has been abstracted, ice-water 
should again be applied to the scrotum. If half an ounce of 
lead-water and an ounce of alcohol be added to each pint of the 
ice-water, the efficacy of the lotion will be still more con- 
spicuous. As the inflammation subsides, the use of lukewarm 
water will be found to agree better than a refrigerant. 

Mercurial Ointment ; Iodide op Potassium Ointment. — In 
some cases, one or the other of these may be advantageously used 
after the inflammation has abated. If the mercurial be selected, 
let it be spread on flannel and the whole scrotum laid in it. Its 
effect in reducing the swelling is sometimes remarkable ; but 
it is liable to irritate the skin so severely that some men cannot 
bear it. If it be allowed to remain for any length of time, it 
will occasionally bring out a vesicular eruption (eczema mer- 
curiale) which will be a source of no little discomfort, if the 



88 GONORRHOEA AND SYPHILIS. 

patient be endowed with a particularly sensitive skin. The 
iodide of potassium, in the proportion of a scruple to the ounce 
of benzoated ointment, may be used instead of the first-named 
ointment, with similar results in diminishing the enlargement, 
and in preventing the morbid action from extending to the 
tunica vaginalis. The potash will likewise occasion an eruption 
upon the integument ; so that its use is not without objections. 
There is this, also, to be thought of: the continual application 
of an unguent to these parts, for several days, will get matters 
into an uncomfortable, dirty condition, which is not easily got 
rid of. Lotions and fomentations, all things considered, are to 
be preferred ; and, in chronic enlargement of the testicle or of 
the epididymis, the following application is the best that can be 
selected : — 

R. Iodinii, gr. ij. 

Potassii Iodidi, " vj. 

Aquse Ferventis, § xvj. M. 

This solution should be used, ivarni, as a fomentation to the 
affected parts, by means of a large sponge, three or four times 
during the twenty-four hours. In cases where the tincture of 
iodine, or either of the above-named ointments, seems to be 
indicated, it will be found particularly agreeable, as well as 
beneficial, to the patient. The sponge should be kept in con- 
tact with the scrotum for thirty or forty minutes at each appli- 
cation. The progress of absorption will thus, in many cases, be 
hastened in the most effectual manner. This local treatment is 
both mild and cleanly, — two not unimportant particulars, in 
which it has the advantage over the tincture and the unguents, 
while its discutient power is not inferior to theirs. 

The watery extract of belladonna, dissolved in the proportion 
of one drachm to a quart of boiling water, and applied by means 
of flannel cloths to the scrotum, and renewed repeatedly, will 
sometimes promptly relieve the pain, and render efficient ser- 
vice in promoting a speedy cure. 

The employment of cathartics should be so timed, if possible, 
that the patient may not be disturbed by their operation during 
the hours of night, — the season which he most needs for 
repose, and of which, if he be robbed, the succeeding day will 



ORCHITIS. 89 

find him irritable, disheartened, and in all respects worse than 
he would have been after a night of rest. Purgatives, there- 
fore, in the early part of the day, and opiates by night, should 
be the order of arrangements. Attention to such small details 
will aid not a little in promoting the comfort and actual conva- 
lescence of many persons, whose genitals are the seat of inflam- 
matory disease, whether acute or chronic. 

A few practitioners still cling to the old method of giving 
mercury to the point of salivation, or even beyond it, in nearly 
all cases of epididymitis, or true orchitis. They find great diffi- 
culty in laying aside preconceived opinions and practices', 
emanating from the high authority of some favorite teacher ; 
and they rely on the internal employment of the above-men- 
tioned article as well nigh omnipotent in controlling every form 
of phlegmasia ; and are slow to believe that mild laxatives, 
quiet repose, anodynes, opiates, narcotics, and diaphoretics can 
accomplish any great amount of good, unless " mercury is 
thrown in" as an accompaniment. 

It should be borne in mind, when mercury is thought of, that 
the dyspeptic, the scrofulous, the nervous, those who have 
naturally a feeble constitution, or who have become debilitated 
by their wild habits, rarely do well under the use of mercu- 
rials, while suffering from any active disease. 

In acute orchitis, there is excessive irritability of the seminal 
apparatus, — an irritative inflammation. The condition of the 
testis is not of the precise nature of inflammation in the strict 
sense of the term, as when we speak of swelled testicle from a 
kick or severe blow. The complaint, in its recent stage, even 
where the symptoms are severe, will sometimes yield readily to 
low diet, a moderate purgative, and the subsequent free use of 
the tincture of hyoscyamus. The latter may be given in 
drachm doses, every three hours, in rice-water or barley-water, 
until a decided narcotic effect is produced. As soon as the 
patient experiences the specific influence of the henbane, the 
local symptoms will almost certainly abate ; and it may after- 
wards be employed in diminished quantities. 

The following combination of antimony, sulphate of magne- 
sia, and colchicum, may likewise be used in many cases with 
good results. It will be sure to maintain a slightly nauseating 
and depressing effect on the stomach, while at the same time it 



90 GONOERHCEA AND SYPHILIS. 

will keep the bowels free, and help to subdue the inflammatory 
diathesis. 

R. Antimonii Potassio-Tartratis, gr. ij. 

Vini Colchici, 5 iij- 

Magnesise Sulphatis, §j. 

Aqua?, § viij. M. 

Give half an ounce of this mixture every two or three hours 
during the day. The frequency of the dose must be varied, of 
course, according to the effect. At bedtime, morphine may be 
required to insure quiet rest. 

M Morphise Sulphatis. gr. j. 

Aquae Camphorse, § iss. M. 

Dose. — One drachm, to be repeated in three hours, if necessary to procure 
sleep. Opiates may be given at any time to allay pain. 



PUNCTURING THE TUNICA VAGINALIS TESTIS AND 

EPIDIDYMIS. 

If the disease has extended to the tunica vaginalis, and effu- 
sion has taken place within that membrane, at any stage of the 
inflammation, the operation of puncturing the tunica should be 
resorted to, and the fluid evacuated. The operation is entirely 
practicable, and gives immediate relief. The puncture is to be 
made with a grooved needle. In true orchitis, where the body 
of the testicle is involved, and the pain severe, in consequence 
of constriction occasioned by the tunica albuginea, punctures 
may be made with a lancet into the testicle itself. This prac- 
tice was first proposed by M. Petit, and is adopted by Ricord, 
Velpeau, and other surgeons. The epididymis may be punc- 
tured in the same manner, and with equal safety. The opera- 
tion does not interfere with the physiological functions of the 
parts in question. It removes the most distressing symptoms, 
and hastens the recovery more rapidly than any other method. 
Cases requiring these measures, however, are comparatively 
infrequent. A timely and continuous application of refrigerant 
lotions, and other antiphlogistic treatment, will usually be pro- 
ductive of amendment and complete cure in a short time. 



ORCHITIS. 91 

Compression of the Testis. — In 1836, Dr. Fricke, surgeon 
to the General Hospital of Hamburg, recommended the appli- 
cation of compression to the testis, by means of strips of adhe- 
sive plaster, as a substitute for every other form of remedial 
appliances, in the treatment of orchitis. Following the recom- 
mendation and practice of Fricke, many other surgeons have 
adopted his method of pressure, and, up to this day, have borne 
testimony to the simplicity of its application, to the slight 
trouble it gives the patient, and to the trifling care and atten- 
tion required on the part of the medical attendant. They also 
speak in the most decided manner of its efficacy in relieving 
pain, and promoting a rapid cure of the disease itself. At St. 
Bartholomew's Hospital, strapping the testicle, in cases of epi- 
didymitis, is regarded as the best plan of treatment. When, in 
consequence of pain, it cannot be carried out, the use of leeches 
to the parts, and the administration of emetics, are resorted to ; 
and these are very efficient means for reducing the inflamma- 
tion of the organ.* To some surgeons, the employment of 
emetics, for the relief of orchitis, may seem a strange mode of 
procedure. The late Professor Nathan Smith, of New Haven, 
recommended this treatment. In some instances of orchitis, I 
have prescribed emetics, and beneficial results have followed 
their use. The relief is sometimes immediate, and is to be 
explained on the principle of what is called revulsive action. 
Hunter tells us that he had known an emetic to remove the 
swelling almost instantaneously. The effects of the remedy, he 
thinks, most probably arise from the sympathy between the 
stomach and the testicles. In acute and severe attacks of 
swelled testicle, or of epididymitis, free vomiting will speedily 
relieve the local symptoms in many cases ; and if, after the use 
of emetics, the surgeon decides upon the employment of adhe- 
sive straps to the testicle, the application will, in all likelihood, 
be less painful. The emplastrum ammoniaci cum hydrargyro 
may be used, or one composed of soap, belladonna, and adhe- 
sive plasters, in equal proportions, and carefully spread on thin, 
firm leather. The strips of plaster are to be cut about two- 
thirds of an inch wide ; and the manner of employing them is 
as follows : The patient is placed in a recumbent position, and 

* Holmes Coote 7 on Gonorrhoea, 1857. 



92 GONORRHOEA AND SYPHILIS. 

the surgeon having gently drawn down the testicle to the lower 
part of the scrotum, the skin of which is stretched over the surface 
of the gland, proceeds to apply the strap in a circular manner, 
commencing from above the insertion of the cord, which must 
be closely embraced in order to prevent the testicle from slip- 
ping through the loose rings of the plaster, when the inferior 
portion is compressed. In this way the operator encircles the 
gland by a succession of straps, each lying over its predecessor 
by one third of its width, until the whole organ is covered. A 
second series of straps is then passed from above downwards, 
and thus the entire testicle is completely enveloped and com- 
pressed. 

When the local symptoms have begun to wane, and the dis- 
eased gland will bear considerable squeezing with the hand, 
compression with straps to a moderate degree may be advan- 
tageously applied, for the purpose of promoting a more rapid 
subsidence of the swelling, the removal of plastic exudation^ 
and of the thickening of the epididymis. At this juncture, 
the internal use of the iodide of potassium will be service- 
able. Should the inflammation be very severe, or be on 
the increase, or if there be great effusion into the vaginal 
sac, compression will do harm. But when the tunic has 
been punctured with the grooved needle or the lancet, and 
the fluid drawn away, pressure can then be beneficially resorted 
to. This plan has often been adopted, and it works well. 
But the most favorable time for the employment of pressure, 
if applied at all, is after the chronic stage has fairly set in. 
After the straps have been adjusted, the patient should be 
confined to the recumbent position and to a low diet. These 
precautions will ward off any tendency to increased inflam- 
matory action, and will render the cure more effectual and 
speedy. The views of Ricord on this subject are thus com- 
municated by Mr. Acton : — 

" Swelled Testicle. — Compression of the testicle by means 
of strapping has now been mostly given up by M. Ricord 
in his hospital ; it is, he still admits, an excellent remedy when 
well applied, but the patient should be seen in the early stages, 
twice a day, and the strapping re-applied, if necessary. With- 
out watching, this treatment is sometimes accompanied with 



ORCHITIS. 93 

disagreeable consequences, which aggravate the complaint; at 
least the French professors think so ; but in London, in private 
practice, I have every reason to be satisfied with the treatment, 
which shortens the duration of the disease very much, and 
dispenses with the usual inconveniences attending these cases. 
M. Ricord places his principal dependence on leeches, mercurial 
ointment and plaster, and, above all, a purgative taken every 
morning, consisting of aperient salts. In this last recommenda- 
tion, I can bear testimony most fully." * 

Mr. Johnson is extremely severe in his condemnation of the 
practice of strapping the testicle. He compares it to the pro- 
cess of the buccaneers of the Spanish Main, who slung their 
prisoners to the yard-arm by the testicles, until they confessed 
where their dollars were laid. "If," says he, "the inflam- 
mation is acute, it is a piece of ridiculous cruelty ; if mild, it 
is disproportionately painful, troublesome to manage, apt to 
lacerate or excoriate the skin, and not a little treacherous. I 
would not wish to be understood that I would never recommend 
it nor have recourse to it. Where concealment is a great 
object, where the patient is not of a nervous habit, and either 
is not sensible to pain, or has the will to bear it, and where 
the inflammatory action is moderate, pressure may be fairly 
tried. Yet even here, with all things in its favor, I warn the 
young surgeon not to expect too much from it. I believe 
that in most cases it is better left alone, and I am mistaken if 
it is not declining in favor, and likely to decline still more. At 
all events, the conclusions I have arrived at and expressed, are 
founded on my own experience and pretty numerous trials 
of it." 

In chronic cases of epididymitis, where there is a lingering 
induration, and a low degree of inflammatory action, extending, 
perhaps, to the glandular portion of the testis, with but little 
constitutional disturbance, the antiphlogistic treatment is not 
required ; it is, in fact, injurious. The patient generally looks 
pale and feeble, and is in just that condition that calls for a 
generous diet and the careful use of bitter tonics. He is liable 
to have uncomfortable nights. He is unfit for much physical 
activity by day, and the sleep of the laboring man is not his. 

* Lancet, December; 1854. 



94 GONORRHOEA AND SYPHILIS. 

He, therefore, requires some artificial aid to ensure the necessary 
repose ; and opiates, sparingly as may be, must be allowed at 
the hour of rest. During the day, free libations of sarsaparilla 
decoction will be found useful. This drink is something more 
than a mere beverage to fill the stomach and employ the kid- 
neys and bladder. Its mild and agreeable tonic qualities endow 
it with more than negative claims to favorable consideration as 
a constitutional remedy. In this class of cases, some mercurial 
preparation may be found serviceable ; but it should hold a sub- 
ordinate place in the general treatment. Whatever form is 
selected, the course should be a very mild one, and should stop 
entirely short of salivation, or even before any but the, slightest 
affection of the gums is perceptible. Two formulae are here 
submitted, either of which will scarcely fail to suit, unless some 
peculiar idiosyncrasy is inherent in the patient. 

R. Pulveris Opii, gr. vj. 

Pilulae Hydrargyri, 

Extract! Hyoscyauri, aa, 3 iss. 

M. ft. pil. No. xxx. 

The other mercurial preparation is the bichloride : — 

R. Hydrargyri Chloridi Corrosivi, 

Ammonias Muriatis, aa, gr. v. 

M. ft. pil. No. lx. 

Of the above pills one may be taken morning and night. 
The condition of the mucous membrane should be carefully 
watched during their use. 

Together with the sarsaparilla and the pills, small doses of 
iodide of potassium may be given, thus : — 

H:. Potassii Iodidi, . . . * , 3 ij. 

Tincturae Cinchonas Composite, § iss. 

Aquas Fontanae, § iij. M. 

Dose. — One drachm thrice a day in compound decoction of sarsaparilla. 

The scrotum should be well supported in a suspensory bag. 
The patient should be encouraged to be abroad in the open air 
as much as possible, and to bathe daily in warm or cold water, 
as he may choose. Dashing a few tumblers of cold water 



ORCHITIS. 95 

against the pubes three or four times in the day, will likewise 
tend to restore the parts to their normal condition. The ap- 
plication of the compound tincture of iodine to the scrotum 
will contribute to the removal of any induration or swelling 
of the epididymis or testicle, and to the perfect restoration of 
the parts to health. 



CHAPTER VI. 
HERPES PILEPUTIALIS. 

This vesicular affection is of frequent occurrence. Men who 
have a long, superabundant preputial membrane are more liable 
to be troubled with the eruption than others. Those who are 
familiar with its appearance in the different stages of its exist- 
ence, and who have much practical experience in its treatment, 
may consider that it is so insignificant, and so unlike any syphi- 
litic sore, that it is hardly entitled to consideration in this place. 
But a correct diagnosis of the eruption is a matter of no little 
consequence ; for an error or confusion here will lead to im- 
proper treatment, to say nothing of the moral bearings imme- 
diately connected with the subject. 

Patients who have contracted herpes upon the penis in con- 
sequence of sexual intercourse, or who have suffered from it as 
a concomitant or sequel of blennorrhagia, have occasion to 
apply to the physician for the purpose of obtaining his opinion 
in the premises. And in some instances herpetic eruptions 
located upon the foreskin have been treated as chancrous prod- 
ucts. Such cases have presented themselves to my notice, and, 
although not frequent, they justify the appropriation of a few 
pages to the exanthem in question. 

Symptoms. — The most common seat of the eruption is along 
the border of the prepuce, where the external and internal sur- 
faces meet. At first, a sensation of heat and smarting, accom- 
panied with considerable itching, draws the attention of the 
patient to the part upon which the eruption is about to be 
evolved. Upon inspection, he notices that it is slightly thick- 
ened and suffused with a preternatural redness ; and if he 
merely touch it with his fingers, he induces a higher degree of 
itching, and rubs it with the expectation of appeasing the sensa- 

(96) 



HERPES PILEPUTIALIS. 97 

tion. In a few hours he perceives, if he looks, an aggregation 
of some dozen or twenty points closely crowded together, and, 
on careful examination, discovers that these pimples are filled 
\with a transparent, watery fluid. They are the vesicles of 
herpes praeputialis. They are about the size of a common pin's 
head, and have been compared to so many transparent glass 
beads reposing on a red base. Instead of one group or cluster, 
two or three may appear simultaneously. They are not inclined 
to enlarge the area they occupy, but have nearly the same di- 
mensions in the latter stages which they had at first. 

Instead of appearing on the confines of the preputial orifice, 
as mentioned above, the eruption may arise at a little distance 
from it, either on the mucous or cuticular surface of this mem- 
brane. In two or three days, the contents of these globular 
vesicles lose their transparency, and are slightly turbid ; and in 
four or five days the matter becomes puriform. The walls of 
the individual vesicles break away, and the eruption is then 
confluent. Next, desiccation ensues, forming a thin, delicate 
^incrustation, which in two or three days is cast off, and brings 
to view a smooth, raw, florid spot, amounting to little more than 
\an abrasion ; or, if it be an ulcerated surface, it is of the most 
Nsuperficial kind, and has no hardened base as in syphilitic 
ulcers. When the complaint is situated on the inner surface 
of the prepuce, the inflammation is generally quite severe. The 
vesicles are usually a little larger than when developed on the 
external surface. The serous exudation of herpes passes rap- 
idly into a lactescent state ; the membrane or sac containing it 
is easily ruptured, and excoriations are produced, which may be 
mistaken for venereal ulcerations. But the speedy development^ 
and progress of the eruption, the level of the exposed surface/ 
after the incrustations have fallen off, with the adjacent healthy 
^tissue, and the ordinarily transient duration of the affection, are 
^sentirely in contrast with the true venereal sore. I must here 
append the qualifying remark, that, if the herpetic action take 
place on the inner surface of the prepuce, no incrustation or 
scab is formed, in consequence of the constant moisture of the 
parts, and their protection from the air. 

If the eruption be not seen by the physician until five or six 
days after its first appearance, — by which time incrustations -" 
may have formed on the skin, or the secretion have passed into 
9 



98 GONORRHOEA AND SYPHILIS. 

a sero-purulent state, — and if its antecedents indicate that the 
patient has been exposed, then it will not be an easy matter to 
say whether the affection be follicular chancres, or simply her- 
petic. Under such circumstances the practitioner can very 
properly claim a postponement for a day or two, before he ex- 
presses a decided diagnosis, meantime keeping matters in statu 
quo by some mild appliances. This is a justifiable and wise 
arrangement, for upon a true recognition of the malady will 
iiang the proper line of treatment. 

The eruption of herpes, when situated upon the foreskin, is 
quite evanescent, if not injudiciously tampered with. It runs 
its course in eight or ten days, and then, in most cases, all is 
over. Occasionally it becomes chronic, and, whatever be the 
treatment, is extremely difficult to cure. Some men, of pecul- 
iar cutaneous susceptibility, are troubled with 'frequent attacks. 
The eruption will readily disappear under the application of 
chloride of soda or lead-water, in weak solution, and will be 
reproduced by a variety of trivial causes, such as the ordinary 
friction of the trowsers, neglect of cleanliness, constipation, 
errors in diet. I have known sea-bathing to occasion this' 
eruption. 

Sometimes numerous minute vesicles are seen clustered on 
the mucous surface of the prepuce, along the fossa just behind 
the corona glandis, and forming a cincture around the organ. 
The accompanying inflammation is moderate ; and when the 
vesicles burst, there is seldom any disposition to assume an 
ulcerative process, and there is a total want of depth to the 
sore. 

The foregoing description corresponds, in the main, with 
the characteristic features presented by herpes praeputialis, 
whether situated on the external or internal surface. The 
complaint derives its chief importance from two facts : one is, 
* that it is too apt to be regarded by the patient, and sometimes 
by the medical adviser, as syphilitic ; and the other, that a man 
having it, or being predisposed to it, is more liable, cceteris pari- 
bus, to contract a venereal affection than one who has no such 
herpetic tendency. 

The following case occurred in my practice a few years since. 
I introduce it here, as illustrating a method of procedure which 
may be applicable to other patients in like circumstances : — 



HERPES PR^EPUTIALIS. 99 

A clergyman from a neighboring State consulted me for a 
preputial eruption, which had troubled him at intervals for 
several years. Leading, as he did, a sedentary and studious 
life, he had become rather thin and dyspeptic, and not a little 
nervous. Like many others, he had a ready faith in the stories 
that are so often concocted among the ignorant and the credu- 
lous, concerning the divers ills that befall the sexual system. 
He was a married man, and his wife an invalid ; but she was 
free from all known uterine or vaginal derangement. My cleri- 
cal patient had, however, imbibed the notion that his wife was 
the cause of his genital trouble, especially as it was aggravated'" 
by sexual intercourse. Another circumstance, still more singu- 
lar, was, he believed his complaint to be syphilis ; and as he 
proceeded in the narration of his case, he remarked, " I sup- 
pose I have got what they call the ladies' disease." I asked 
him if he considered his wife a virtuous woman. " As pure as 
the Virgin Mary," was his reply. I requested to examine him ; 
and upon inspecting the virile organ, the prepuce was found to 
be much elongated and narrow, its whole border thickened, 
slightly everted, and covered with herpetic disease. A little 
extra force brought the prepuce fairly back, so as to expose the 
glans, which was covered with a dense sebaceous deposit.^ The 
gentleman was quickly told that the fons et origo mali was 
within himself, and that his trouble, instead of being syphilitic, 
was the offspring of malformation and neglect of cleanliness. y 
The treatment proposed was, to keep the bowels regular, exer- 
cise freely in the open air in all good weather, practise daily 
ablution of the whole body and limbs in cold water, and away 
with all thoughts of the " ladies' disease." As a topical appli- 
cation, the following lotion was prescribed : — 

R. Liquoris Sodae Chlorinatae, 5 iij- 

Aquse Fontanse, § x. M. 

To be applied constantly by means of a soft rag ; also to be 
injected between the glans and prepuce repeatedly during the 
day. Some months after prescribing for the patient, I ad- 
dressed to him a note, and received the following reply : — 

" With respect to the subject concerning which you wrote me, 
I would say : I followed your directions for nearly six months ; 



100 GONORRHOEA AND SYPHILIS. 

received relief from smarting and soreness in about six weeks. 
The disease seemed to be removed almost entirely in six weeks. 
Occasionally I feel a little smarting and experience a little in- 
flammation about the once diseased place. At such times, I 
resort to your prescriptions, and after one or two applications of 
the wash, etc., the difficulty is removed. I think yours is the 
remedy for such a complaint as mine was. Allow me to thank 
you most cordially for the benefit I have received from your 
directions. I. B." 

Case II. — Herpes prceputialis twice in the same man in 
connection with acute g-onorrhcea. 

June 15, 1856. — Patient A. K., aged twent} r -six years. Thin, 
tall, spare frame. Twelve days ago fell into bad company, and, 
as a consequence, contracted gonorrhoea, which appeared in 
five days after exposure. To-day the discharge is copious, thick, 
and puriform. Ardor urinae for last two days, and painful 
erections and chordee the last two nights. Prepuce very long, 
contracted, and inflamed ; about the orifice, numerous herpetic 
vesicles have formed. Complete retraction of prepuce difficult. 
No balanitis ; no swelling of inguinal glands. 

For the blennorrhagia, cubebs were prescribed, and in a few 
days the discharge ceased. The herpetic eruption, produced by 
the irritation of the urethral secretion, continued undiminished 
for four weeks before the prepuce Was restored to its normal 
condition, notwithstanding the free use of opiate lotions, lead- 
water, chloride of soda, etc. 

November 29, 1856. — A. K. has signalized his folly by 
plunging into danger anew. The exposure happened on the 
night of the 14th ; and on the morning of tire 20th, the present 
attack of urethritis declared itself. A sense of shame prevented 
him from calling earlier for treatment. The gonorrhoea on 
this occasion degenerated into a gleet, which lasted for three 
months. The reason for this was, the patient became reckless 
of all directions and restrictions. The prepuce was again the 
seat of herpetic disease, more severe than during the previous 
attack. The inguinal glands of the left side were enlarged, 
and the condition of things for a short time was similar to that 
seen in genuine follicular chancres or syphilitic ulceration of the 
prepuce. Had the case been seen by a surgeon for the first 



HERPES PILEPUTLALIS. 101 

time while at its acme, he would have found the re'al character 
of the disease a question not easily settled, unless a detailed 
history of it from the commencement had been furnished. But 
as the complaint originated in a vesicular eruption, and as fol- 
licular chancres and syphilitic preputial ulcerations never have 
such an origin, the differential diagnosis could be readily made 
out. The herpetic affection did not quit its hold of the prepuce 
until more than eight months had elapsed. 

Treatment. — If herpetic vesicles appear on any portion of 
the inner surface of the prepuce, the application of dry lint will 
frequently cause them to vanish ; the liquor plumbi, in the pro- 
portion of a drachm to four ounces of water, will do the same ; 
and thus prove the non-venereal character of the eruption. 
Sometimes the solid nitrate of silver, lightly drawn over the 
part every three or four days, will prove an effectual remedy. 
The hydrocyanic acid is likewise a valuable article to be em- 
ployed as a lotion in obstinate cases of herpes, not only when 
situated on the prepuce of the male, but also when it attacks the 
genitals of females. The following preparation will be found 
useful : — 

R. Acidi Hydrocyanici, 5 ij- 

Spiritus Rectificati, 5 ij- 

Aquae Destillatse, § iv. M. 

To be applied by means of- lint. 

The arseniate of iron, in common with other preparations of 
arsenic, possesses properties which render it worthy of a trial. 
The advantage of this substance is, that it may be administered 
in sufficient quantities, without giving rise to any of the un- 
pleasant consequences which sometimes follow the use of other 
arsenical remedies. It should be given in graduated doses, 
commencing with one fifteenth of a grain once a day for the first 
eight days ; then one fifteenth twice a day for eight days more ; 
after which, the fifteenth of a grain three times a day, making 
the maximum daily amount to be one-fifth of a grain. The 
formula I employ is : 

R. Ferri Arseniatis, gr. iv. 

Extract! Gentianae, 9ij. 

Pulveris Glycyrrhizae, 9iv. 

M. ft. pil. No. lx. 

9* 



102 GONORRHOEA AND SYPHILIS. 

The pills should be taken on a full stomach. They are com- 
patible with the use of almost any other medicine which the 
surgeon may wish to employ, and may be continued uninter- 
ruptedly for three or four months, if necessary. They are not 
only useful in herpes, but also in squamous affections. The 
arseniate of quinine is likewise a valuable medicine for the same 
cutaneous maladies. The dose is one third of a grain blended 
with the extract of gentian, and taken directly after the morning 
and evening meal. The tincture of the muriate of iron, twenty 
drops three times a day, in a gill of water, is also useful in 
obstinate cases of herpes prasputialis. 

Whatever course of treatment is pursued, it should be a prin- 
ciple of cardinal importance to rectify any constitutional de- 
rangement that may be present. 

Simple and insignificant as the foregoing eruption is repre- 
sented to be by some authors, it occasionally shows itself more 
than a match for the skill of the medical attendant, and remains 
upon the patient as a source of sore vexation. 



CHAPTER VIL 

ECZEMA PRJEPUTIALIS. 

In bilious and sanguineous subjects, who have a dry, un- 
perspirable skin, and indulge in strong proclivities for eating 
and drinking whatever comes before them at table, the pre- 
putial integument, especially if there be a redundancy of it, 
sometimes proves to be a favorable locality for the develop- 
ment of this complaint. Its occurrence, however, is less frequent 
than the preceding affection ; but of the two, it is usually the 
more serious and persistent. Although both present a common 
elementary type, — that is, a vesicle, — yet the course pursued 
by the two is widely different. The solitary vesicles of eczema 
are smaller and more acuminated than those of herpes. They 
are accompanied by a sensation of heat and pruritus of higher 
intensity than the herpetic affection, and no application seems 
adequate to appease these annoyances for the time being. After 
the vesicles have occupied the prepuce for a day or two, they 
are inclined to become confluent ; and in consequence of the 
effusion of serum beneath the epiderma, they form small, 
oblong, flattened bullae, half the size of a pea at the base. The 
cuticle of these multilocular vesicles is easily broken, and a 
glutinous exudation, having the peculiar sickly odor well known 
in eczema when situated elsewhere, is distilled in sufficient 
quantity to stand in drops on the inflamed and denuded derma. 
The malady, at first, covers but a small patch of ground, but is 
rarely content to keep within its original limits. It has a 
diffusive tendency, and in this respect differs from herpes, which 
has no disposition to spread when situated on the same part. 
Unlike the eruption of herpes, also, it seldom implicates the 
mucous lining of the prepuce, but in most instances extends 
over the entire external surface, seizes upon the dartos, is now 
severe, now better, fitful in its behavior, for a few days highly 
inflamed and yielding a copious exudation, then occasioning 

(103) 



104 GONORRHOEA AND SYPHILIS. 

scarcely any moisture, itching, or redness ; but a flimsy lam* 
inated incrustation is formed, blended with newly formed 
cuticle. This latter condition suggests to the inexperienced eye 
a proximity of cure ; but in lieu of this, a few rough, involun- 
tary scratches with the finger nails, which the affected parts are 
pretty sure to receive, reproduce the eruption in two-fold sever- 
ity, and dissipate all hope of immediate deliverance from this 
local trouble. 

For .the most part, the eruption appears in connection with 
chronic blennorrhagia. The secretion which it yields spreads 
over the sound skin, and by the irritation it excites, causes an 
extention of the trouble in every direction. It is very apt to 
assume a chronic form, and when it does it sometimes simulates 
psoriasis. It is, however, but a resemblance. I do not believe 
it ever loses its identity, or that it undergoes a transformation 
into another disease. We might as well say that one animal 
or one plant degenerates into another. The two maladies in 
question are different in appearance, and require different treat- 
ment. Even where the vesicles have ceased to form in succes- 
sive crops, and when the prepuce and even the scrotum remain 
covered with scales, — these, as the result of eczematous action, 
are less friable, less furfuraceous, and more laminated, broader 
and flatter, than the scales of psoriasis. Furthermore, in long- 
continued eczema of the prepuce and dartos, the integument, 
after the scales, are removed, does not present that smooth, red, 
polished, elevated surface which is observed in psoriasis ; but is 
rough, chapped, and marked by fissures, from which, as well as 
from the sudatory apparatus and the hair-follicles, a frequent 
and copious oozing of the irritating fluid of eczema will take 
place. Eczema, of however great duration it may be, rarely 
ever loses its natural tendency to form vesicles on some portions 
of the integument,, which is the seat of the complaint. They 
appear here and there, as solitary specimens, just outside or 
inside the borders of the affected district, remain for a few days, 
a new source of trouble to the patient, and then disappear. 
These facts or circumstances do not happen in psoriasis. Some- 
times the eczematous eruption, especially if it spread over the 
dartos, or along the upper part of the thighs, or over the pubic 
region, fraternizes with impetigo ; that is, the exudation beneath 
the cuticle consists, from almost the very beginning, of a small 



ECZEMA PILEPUTIALIS. 105 

number of pus globules suspended in a large quantity of serum, 
and giving it an opalescent appearance ; and the inflammation, 
the heat, the scalding, and burning sensations, that accompany 
the evolution of the eruption, attain a higher degree of activity 
than in simple eczema. The scabs and incrustations become 
thick, firm, and rugged. The affection having these impetig- 
inous characters, is partial to the upper part of the thighs in 
both sexes, and is occasionally met with as the joint production 
of chronic blennorrhagia and want of cleanliness, and has been 
mistaken for a true syphilitic pustular disease. 

Treatment. — The means best adapted for treatment must 
necessarily vary according to the degree of severity which the 
disorder assumes. Ordinarily, but a limited portion of integu- 
ment is involved at any one time, and local applications of a 
soothing, unstimulating kind may be relied upon. During the 
day the following lotion may be used : — 

R. Liquoris Plumbi, 5 ij- 

Glycerinae, 5 iij- 

Aquse Fontanae, § viij. M. 

At bedtime, the parts may be covered with the benzoated 
oxide of zinc ointment, prepared as follows : — 

R. Gummi Benzoini pulveris, B iij- 

Adipis prseparatae, § iij. 

Liquefac, cum leni calore, per horas viginti quatuor, in 
vaso clauso ; dein cola per linteum, et adde, 

Oxydi Zinci purificati, § ss. 

Misce bene, et per linteum exprime.* 

The benzoin prevents decomposition in the above ointment ; 
so that it does not become rancid as is the case with ointments 
generally ; and as a soothing, local application, it is all that can 
be desired. I have prescribed it almost daily during the last 
year. If there be much discharge from the eczematous surface, 

* " The benzoated oxyde of zinc ointment, properly prepared, is the most 
perfect local application for all chronic inflammations of the skin that is 
known. " — Erasmus Wilson, on the Skin, fourth edition, p. 73. 



106 GONORRHOEA AND SYPHILIS. 

it should be wiped off with a soft rag, but not washed ; and the 
ointment may be used two or three times during the day, if the 
surgeon choose, instead of a lotion. The old prejudices against 
" greasy applications " need not be raised against the ointment 
here recommended. The sulphuret of potash is prescribed by 
some writers. This article has an extremely unpleasant odor, 
soils whatever it touches, and my experience with it as a topical 
application leads me to regard it as inferior to the remedies 
above suggested. Acetic acid, six drops to the ounce of water, 
and used repeatedly during the day when the pruritus is 
troublesome, will be found beneficial ; so, also, equal parts of 
lemon-juice and water, dabbed upon the spot with a bit of rag, 
will, in many cases, wholly quiet the itching. 

When the eruption attacks the scrotum and thighs, it is nearly 
useless to rely on mere topical applications. The patient re- 
quires constitutional treatment. The first of such remedies in 
importance, are moderate saline cathartics, provided the patient 
is of a full habit. If of an opposite constitution, aperients will 
be sufficient. In all stages of the eruption, a free state of the 
bowels should be maintained. The alimentary canal can be 
made to perform excellent service to the skin, and should never 
be allowed to remain idle a single day. The uropoietic appa- 
ratus may also be employed in the work of relieving the cuta- 
neous vessels. I have derived advantage from the use of bitter- 
sweet and common yellow dock-root combined as follows : — 

R. Solani Dulcamarse, §j. 

Pulveris Radicis Rumicis Obtusifoliae, § ss. M. 

Let these ingredients be put into a quart of water, and sim- 
mer over a slow fire, until the water is reduced to a pint and a 
half. Strain the decoction, and direct the patient to take an 
ounce of it three times a day. The quantity may be gradually 
increased, unless some unpleasant effects, such as vertigo, 
nausea, or palpitation, are induced. After the decoction has 
been taken for two or three days, its influence is usually mani- 
fested in a decided manner by the increased action of the kid- 
neys and bowels; and amendment of the cutaneous affection 
follows very soon afterwards. 



ECZEMA PBJ3PUTIALIS. 107 

The liquor potassae and the aqua acetatis ammoniae are like- 
wise remedies which ought not to be omitted. Either of 
them may be taken in liberal doses, ,unless some known cir- 
cumstance should exist to contraindicate their use. In regard 
to the employment of arsenical preparations, the course recom- 
mended in herpes praeputialis can be prescribed with equal 
advantage in eczema of the same or neighboring parts. 



CHAPTER Yin. 

IRRITABILITY OF THE BLADDER. 

In some cases of blennorrhagia which become chronic, a 
certain amount of irritability of the bladder is induced, which 
often requires medical treatment. Persons of a nervous tem- 
perament are particularly liable to suffer from this affection, 
while those of a robust, sanguineous constitution, are more 
disposed to cystitis or inflammation of the bladder. In irrita- 
bility of this viscus, the mucous membrane becomes morbidly 
sensitive ; and the presence of the urine is quite insupportable. 
The patient complains of a sense of uneasiness in the lumbar 
region, about the verge of the anus, at the extremity of the 
penis, and above the pubes ; he is continually haunted with 
a desire to pass urine, and unable to endure the smallest accu- 
mulation of this fluid. It is seldom that he suffers much pain 
anywhere, but his nervous system is wrought up to a state 
of constant excitement. He loses all relish for food, and sleep 
departs from him ; and if these abnormal conditions are not 
removed, the general complexion of the symptoms will simulate 
those of cystitis, or what is still worse, the latter disorder 
will actually set in. In mere irritability of the bladder, the 
system is rarely affected ; whereas in inflammation it is always 
involved. This is the rule, and should be borne in mind in 
forming the diagnosis. Simple irritation may also be known 
by the absence of that profuse secretion of mucus, which is 
a prominent characteristic of catarrhus vesicas.- In the latter 
affection, immense quantities of thick, semi-transparent, tena- 
cious mucus, and coagulable lymph, accumulate in the bladder, 
and frequently block up the urethral canal, so as to impede, 
or wholly prevent, the flow of urine. Sometimes the complaint 
extends to the ureters and kidneys, which contribute a share 
of the secretion that is produced in such extraordinary quan- 
tities. 

(108) 



IRRITABILITY OF THE BLADDER. 109 

In irritation, the urine is free from any admixture of blood ; 
in inflammation, it is more or less deeply tinged. In inflamma- 
tion, there is constant and severe distress in the rectum, with 
a sensation of heat and throbbing in the part as well as along 
the course of the perinaeum ; and if the surgeon make gentle 
pressure upon the supra-pubic region, the patient will complain 
of lancinating pain, which is not the case when the viscus is 
merely in an irritable state. In inflammation of the vesical 
mucous membrane, the symptoms, both local and constitutional, 
are all of a much more grave and intense character than those 
which prevail in uncomplicated irritation. 

An acute attack of irritation occasionally passes into a chronic 
state, and may lead to suspicion that a calculus exists in the 
bladder ; and this idea may suggest to the surgeon the impor- 
tance of introducing the sound ; whereas, if this instrument 
be used, the chances are that it will excite inflammation in the 
organ, which has been thus needlessly explored. The patient's 
condition goes on from bad to worse. No stone is found ; 
and a little reflection upon what has passed, and a more abid- 
ing and deliberate attention to what is present, will now enable 
the surgeon to form a correct diagnosis of the case. To such 
a course of procedure with such results as are here mentioned, 
the annals of surgery abundantly testify. 

The most salient points of difference between irritability of 
the bladder and a calculus within its cavity, may be summed 
up in a few words. In the latter disease, the moment of the 
patient's greatest suffering is after the last jet of urine has 
escaped from the meatus urinarius ; whereas, if he have only 
an irritable bladder, the time of his greatest distress is before 
the urine is evacuated ; and the amount of pain experienced 
will be in proportion to the quantity of urine contained in the 
bladder. If the medical attendant have a knowledge of these 
simple facts, he will have no occasion to introduce an instru- 
ment for the purpose of resolving doubts and arriving at a true 
diagnosis. 

When irritability of the bladder assumes a chronic character, 
it is one of the most formidable and dreadful maladies that can 
befall the patient. He is compelled to keep aloof from society, 
and his life of seclusion is also a life of almost unremitting tor- 
ment. If irritation and inflammation co-exist, as they some- 
10 



110 GONORRHOEA AND SYPHILIS. 

times do, the latter, being the more important of the two, 
should occupy our chief attention. 

TREATMENT OF IRRITABLE BLADDER. 

In the acute stage of this disease, the free use of opium is re- 
quired. The administration of an enema containing a drachm 
of the tincture of opium, is one of the first things to be done 
when the physician is called to relieve a sudden attack of the 
complaint. Should the case be very urgent, the enema may be 
repeated in one hour. No remedy is more certain or speedy 
in its action than this. The laudanum may be put into about 
three ounces of warm water. The patient should keep the 
recumbent posture. Fomentations, as hot as can be borne, 
should be applied to the perinaeum, the pubes, and hips ; a 
warm-water bath, twice a day, will also materially aid in allay- 
ing the irritable condition of the bladder, and will quiet the 
general nervous excitement of the sufferer. Aperients should 
be administered in sufficient quantities to keep the alimentary 
canal in a soluble condition ; and for this purpose, small doses 
of castor-oil will be found better than anything else of the kind. 
It should be given in the early part of the day. Its action may 
be promoted by an enema of warm water. 

The individual should occupy, if possible, a large, well-ven- 
tilated apartment, and not be subjected to the annoyance of 
company — not even that of intimate associates. His welfare 
will be essentially enhanced by having quietude reign around 
him at all times. He should abstain from drinks as much as 
possible, especially those that contain a large amount of sac- 
charine matter in solution. Even tea, coffee, and milk will be 
injurious. They tend to increase renal action, and thus add to 
his sufferings. If he complains of thirst, cold water will be 
the best antidote. Liquor potassse, ten drops to a wine glass 
of cold water, or in as much weak hop-tea, every two or three 
hours, will be found beneficial. A blister should be applied 
over the sacrum or over the pubes. The counter-irritation thus 
created, will be very useful, and no apprehension of strangury 
need be entertained. 

To keep the bladder in a state of repose, a short gum-elastic 
catheter should be introduced as far as the distal end of the 



IRRITABILITY OF THE BLADDER. HI 

urethra, but must not be allowed to enter the bladder. The 
length of the instrument should be nine inches, which will 
correspond with the length of the urethra, almost invariably.* 
It should be carefully secured to a bandage carried between 
the thighs and around the loins. The instrument need not 
be withdrawn from the urethra oftener than once in twenty- 
four hours. 

An infusion of diosma crenata, taken freely, either alone or 
with decoction of pareira brava, has long enjoyed the reputa- 
tion of tranquillizing the local irritability when the disease has 
passed into a chronic state. Warm-water injections into the 
bladder are serviceable when much mucus is present in the 
urine. They may be employed twice in the twenty-four hours. 
If the contents of the bladder are offensive, ten or twelve 
drops of chloride of soda may be added to each ounce of the 
injection. Nitric acid, in the proportion of two drops to the 
ounce of water, is recommended by Sir Benjamin C. Brodie 
and by Mr. Henry Thompson, as an injection. f Nitrate of 
silver has been employed for the same purpose, in the propor- 
tion of half a drachm to the ounce of water, in cases where 
the milder forms of injection fail to check the albuminous 
secretion into the bladder. The operation is a painful one, and 
it is frequently necessary to repeat it in four or five days. Its 
effects are said to be, generally, highly beneficial. It is best 
adapted to cases requiring a strong, stimulating application to 
the affected organ, as when the mucous membrane is in an 
atonic and relaxed condition, and when there is no evidence 
of any inflammatory action. Injections would be inadmissible 
during the acute stage of the complaint ; but in all chronic 
cases they are serviceable, not only in relieving irritability of 
the bladder, but also in removing any collection of mucus that 
may be retained within its cavity. The best and most approved 
method of administering injections is the one employed by 
Mr. Fergusson, which is, to introduce the water in a contin- 
uous stream by means of a double syringe like that of a stom- 
ach-pump, f 

If the complaint terminates in inflammation of the bladder, 
then, in addition to the liberal use of opiate enemata, hot baths, 

* Astley Cooper. t Lancet, 1854, p. 594. J Miller's Surgery, p. 490. 



112 GONORRHOEA AND SYPHILIS. 

and blisters, as recommended in irritable bladder, it will also be 
expedient to resort to antiphlogistic measures. Twenty leeches 
may be applied to the perinseum, and the bleeding promoted by 
warm-water fomentations. If the use of an opiate by the 
mouth be required, the sulphate of morphia may be selected : — 

R. Morphae Sulphatis, gr. iij. 

Misturae Camphorae, § iij. M. 

Dose. — One drachm, pro re nata. 

In a non-inflammatory condition of the bladder, or when the 
inflammatory action has become chronic, the balsam of copaiba 
should be prescribed with a view to arrest the formation of the 
thick albuminous deposit. No remedy more promptly checks 
this morbid secretion than the balsam. It can be given in cap- 
sules, from six to eight per diem, or in mixture with other 
ingredients, as mentioned under the treatment of blennorrhagia. 

If the urine should become acid, which can be known by its 
turning blue litmus paper red, alkalies will be indicated. 

R. Potassa? Carbonatis, 9j. 

Syrupi Aurantii, 3 ij« 

Aquae, § iss. M. 

To this add the powder of citric acid, gr. xxiv. 

Let the patient drink the mixture while it is effervescing. 
The draught is to be repeated several times in the day. Lemon- 
juice makes a good substitute for the citric acid. 

If the urine should contain an excess of alkaline properties 
— turning red litmus paper blue — the dilute nitric acid, to the 
amount of a drachm each day, in three gills of water, should 
be taken in divided portions. The wine of colchicum, under 
these circumstances, may also be prescribed with marked 
benefit. 



CHAPTER IX. 

EXCORIATIONS. 

Simple abrasion of some portion of the "glans penis, or of 
the mucous or cutaneous surface of the ^prepuce, is not an 
^infrequent accident resulting from sexual congress. The injury 
takes place where there is a want of co-aptation in the relative 
size of the organs, or where the parties engage in their amative 
embraces in an impetuous manner. The most frequent locality 
of the disease is near the fraenum, or just behind the corona, 
among the glandulae odoriferas. Although it is one of the non- 
specific affections incidental to the venereal act, it is very apt to 
be viewed by the patient with alarm, as being syphilitic. The 
excoriation is sometimes situated on the free edge of the pre- 
puce, especially when the latter is long and narrow, and does 
not readily retract behind the glans. Such a prepuce is liable 
to receive the brunt of the effort ; and the seat of injury is along 
the line of union between the two surfaces, oftener than else- 
where ; and least in frequency the lesion is met with upon the 
dorsum of the glans and on the external surface of the prepuce, 
a few lines from the orifice. When situated within the pre- 
putial cavity, the abrasions, if neglected, sometimes assume an 
appearance closely allied to chancres. They ulcerate, occasion 
little or no pain or smarting, and are attended with only a mod- 
erate inflammation. If early treated, they can be easily cured 
by simple applications ; but if allowed to take their own course 
for a week or two, uninfluenced by remedial means, the sores or 
ulcerations which form upon the abraded spots are extremely 
reluctant to heal, — not on account of any peculiar, bad quality 
inherent in them, but partly because of the structures in which 
they are situated, and partly from the fact that the secretions to 
which the diseased surface is exposed keep up a morbid irrita- 
tion. Generally, there is but one irritated patch. The patient 
states that it attracted his attention immediately after the 

10* (H3) 



114 GONORRHOEA AND SYPHILIS. 

exposure in which it originated ; and this fact is important in 
aiding the physician to distinguish it from chancre, at whatever 
period he may be consulted in the case ; for the latter affection 
is always more tardy in manifesting itself after the application 
of the cause. If, when the medical attendant sees the individual 
for the first time, the part is in a state of ulceration, the interval 
between the exposure and the development of the disease, is a 
point that should always be ascertained. If he computes the 
time between the cause and the effect by hours instead of days, 
it is almost certain that the excoriations or ulcerations are not 
venereal. It is worthy of recollection that the item of time fur- 
nishes one of the surest " rational signs " which the case admits 
of ; and whatever the anatomical appearances may be, as sug- 
gestive of the nature of the affection, they never, in my estima- 
tion, transcend in value the chronological evidence derived from 
the patient. So far as physical characters go, we are unable to 
distinguish these sores from chancres, to which they have a 
strong resemblance in situation, size, etc. 

Ulcerations resulting from abrasions of the cutaneous surface 
of the prepuce, bear less resemblance to chancres than those 
situated within the orifice. They are on a plane with the 
adjacent healthy integument, and of course do not present the 
elevated, sharp, perpendicular edges which characterize chan- 
cres ; nor have they any indurated base, which many chancres 
have. They are irregular in form and size. After the excoria- 
tion has healed, the integument remains quite tender for some 
time ; and a slight cause, such as friction of the part against the 
clothing, is sufficient to awaken the injury anew. Such relapses 
are not uncommon, and they are generally worse than the 
original attack. The surface of the excoriation is larger, and 
the morbid action now reestablished is more difficult to subdue. 
It may assume a chronic type, and give rise to a sympathetic 
bubo in the groin, so that the recurrence of the accident may 
turn out to be a most unfortunate event both to surgeon and 
patient. By it, the latter becomes disheartened and alarmed, 
distrusts the diagnosis that may have been given in the early 
period of his illness, impugns the treatment adopted, and ex- 
presses a desire, perhaps a determination, to be treated for the 
venereal disease, — a complaint which he has not got. Thus 



EXCORIATIONS. 115 

the surgeon has a troublesome affair to manage. In illustration 
I submit the following 

Case. — Excoriation of prepuce — relapse — eruption on the 
glans penis, and on the body, etc. — disagreement in diagnosis. 

January 7, 1857. — A. B., aged 19. Salesman. Had inter- 
course with a girl of the town on the night of December 3.1, 
1856. Was conscious, before he had completed the act, that he 
had wounded the prepuce. Next morning the part was swollen, 
and he discovered an abrasion as large as the thumb nail on the 
dorsal aspect of the external surface, near the orifice. By the 
use of a weak solution of chloride of soda, the injury was healed 
in four or five days. On the 16th of January, the young man 
again called for treatment. He had been actively employed at 
his labors in a wholesale establishment, and his troubles had 
reappeared with increased severity. The excoriation now occu- 
pied more or less of both preputial surfaces, and yielded a free 
exudation, which irritated the adjacent parts not a little. The 
glans was uncovered and inflamed, but there was no abrasion 
upon it, nor was there any urethral discharge. 

The patient was advised to suspend business and remain quiet 
at his boarding-house for a few days. This he said he could not 
do without the hazard of exciting suspicion or perhaps forfeiting 
his clerkship. He was told that simple as his local difficulty 
appeared to be and really was, it would probably resist all sorts 
of treatment, unless he refrained from exercise. Under these 
circumstances different lotions were ordered, and small doses of 
the iodide of potassium prescribed for internal use. After the 
potassium had been taken for about two weeks, a slight eruption 
appeared on the face and chest. This salt was discontinued, and 
the arseniate of iron, in the dose of one seventh of a grain each 
day, was substituted. The bowels were kept free by salines. 
For six weeks this treatment was assiduously pursued to no 
good purpose. The inguinal glands became enlarged and ten- 
der. On the glans, minute vesiculo-pustules appeared from 
time to time in successive crops. Trivial fluctuations of amend- 
ment and relapse took place. Such is the history of the case up 
to the morning of 

February 10th. — At this date, numerous well-defined, scar- 



116 GONORRHOEA AND SYPHILIS. 

let-colored, erythematous blotches were seen upon the trunk, 
hips and thighs, shoulders and arms. They were totally differ- 
ent, in appearance, from the eruption spoken of above, in con- 
nection with the use of the iodide of potassium. Nothing like 
a papule could be felt, as in lichen, or in recent examples of 
psoriasis guttata. They were on a level with the adjacent skin. 
What gave rise to this blotchy condition of the integument, I 
am unable to say. It remained about three weeks, and then 
disappeared. Three or four sores broke out just behind the 
glans penis, and two small ones were perched exactly on the 
corona, and the whole glans was inflamed. All these phenom- 
ena, together with the disease of the prepuce, the % tumefaction 
of the inguinal glands, and a soreness within the buccal cavity, 
of which the patient complained, presented an ensemble of 
symptoms allied to real syphilis. A crisis happened to-day. 
The patient informed me that, although I had assured him that 
his complaint was not venereal, a certain' respectable physician, 
whom he named, had casually heard of his condition, and had 
said that such a case must be syphilis and nothing else ; and he 
(the patient) desired that I would treat him for that. I de- 
clined, and the patient was dissatisfied. I proposed that he 
should call at mid-day, when I would exhibit him to some of 
my medical friends. Three came, examined the case, and, sure 
enough, decided that it was syphilis. Thus, seemingly, the 
tables were fairly turned against me. In the evening, the 
young man called again. I informed him of this decision, and 
told him my own views were not changed. To put an end to 
the question, it was now agreed that it be referred to Dr. S. D. 
Townsend, Senior Surgeon of the Massachusetts General Hos- 
pital, who pronounced it to be non-venereal. The patient's 
mind was at rest. He agreed to keep house, according to pre- 
vious advice, and was directed to dress the penis with a weak, 
black wash; that is, 9ss. of the submuriate to §iv. of lime- 
water. This he did, and in six days was well. The foregoing 
case is not devoid of instruction. 

If the surgeon is consulted before the excoriations have 
advanced to a state of ulceration, local applications will be 
sufficient to cure the patient at once, in all ordinary cases. 
The chloride of soda, Goulard's extract, or dry lint, as recom- 
mended for preputial herpes and eczema, will accomplish all 



EXCORIATIONS. 117 

needful purposes, Should other local measures be required, 
the following lotion will be found useful : — 

R. Liquoris Potassse, 5 j- 

Glycerinse, . . . 

Acidi Hydrocyanici, aa, 5ij- 

Aquae Fontanae, § iv. M. Lotion. 

This will allay the itching and smarting, and may be kept on 
the part as a dressing. Oiled silk or gutta percha tissue should 
be used as an envelop. 

R. Liquoris Plumbi, , . . 3 j. 

Vini Opii, '• • 5ij- 

Spiritus Rectificati, 5j- 

Aquae, § iv. M. 

This last lotion is a good remedy in cases characterized by a 
high degree of inflammation. The black wash, of the strength 
mentioned above, is likewise a valuable topical application 
where the affection has become chronic and the inflammation 
feeble. The black wash, of maximum strength, is apt to pro- 
duce a minute eruption on the glans and prepuce when applied 
to these parts. At night, the benzoated zinc ointment will be 
appropriate. The parts should be soaked in water, as warm as 
can be borne, three or four times during the day. If the ulcer- 
ations pertinaciously maintain their ground, the dilute nitric 
acid or the tincture of muriate of iron will constitute a suitable 
internal treatment. All stimulants, externally or internally, 
will only exasperate the morbid condition. 



CHAPTER X. 
URETHRAL PAINS. 

Now and then, a man who has been cured of blennorrhagia 
reports that he is troubled with pains in some portion of the 
urethra, usually in that part which is anterior to the scrotum. 
Sometimes the pains are seated farther back, as if near the 
neck of the bladder, from which they seemingly radiate in 
every direction. These sensations are pretty constant, although 
marked at irregular intervals by exacerbations of great sever- 
ity, and amounting, in the estimation of the patient, to a bona 
fide disease, engrafted upon the preexisting malady, or, at 
least, in some way connected with it. Occasionally, the testi- 
cles participate in the affection ; and if the man happen to 
cross his legs or bring his thighs together carelessly, he experi- 
ences in these glands a sharp pain, and at the same moment a 
sensation of faintness, with nausea and other distressing symp- 
toms of a nervous character. In most instances, these neural- 
gic affections are to be regarded as a consequence of a previous 
gonorrhoea, in which the bladder sympathized, and in which the 
treatment was necessarily protracted, before being crowned with 
success. In other cases, these sensations haunt the individual 
for a long period, when there has been no want of success, and 
no impropriety in the treatment, where the patient has been 
prudent in his habits, and is not of a particularly nervous con- 
stitution. 

In examining a person who has the symptoms in question, no 
abnormal condition of the urethra or bladder can be detected ; 
the stream of urine is natural ; the catheter or sound traverses 
the canal with ease throughout its whole extent, and enters the 
bladder without obstruction ; the meatus urethra? looks healthy, 
and no tender point is observed when the penis is squeezed 
between the thumb and finger. In fact, it is said that the latter 

(118) 



URETHRAL PAINS. 119 

manipulation actually affords relief. The patient is frequently- 
teased with a disposition to urinate, every few minutes, which 
shows that the bladder still sympathizes with the urethra. If 
an examination be made per anum, the prostate gland is found 
to be healthy, and, whatever means are employed to ascertain 
the condition of the entire genito-urinary system, no structural 
lesion can be discovered. If the patient be of a nervous tem- 
perament, the unexpected circumstances in which he finds him- 
self exert a most depressing influence upon his mind. He is 
sure to magnify the severity of his sufferings in the part, and to 
regard them as the harbinger of something worse to come. 
For the time being, he is well nigh a monomaniac, and for an 
explanation and cure of his case he consults the physician or 
surgeon. 

Treatment. — Several methods of relief are at our command. 
Constant compression of the penis, by means of diachylon 
plaster, cut into narrow bands, is often a successful mode of 
treatment. The bands should be about one third of an inch 
wide, and long enough to allow the ends to lap over each other. 
The compression should commence at the glans, and be as 
decided as may be compatible with the flow of urine. The 
plasters must be renewed as often as they become deranged. 
If the pains are seated behind the scrotum, compression of the 
penis will do no good. Blisters to the perinaeum are, in many 
cases, perfectly efficacious in removing urethral pains ; or, what 
is more convenient, cantharidal collodion, which can be applied 
either to the penis or perineal region. In some instances, vesi- 
cation over the sacrum will answer, and if the circumstances of 
the patient require him to be engaged in active business, and 
will not allow of his being blistered on the perinseum, the integ- 
ument of the sacrum may be selected. The blister will require 
to be repeated, perhaps, every ten days for several weeks. 
Meantime, other remedies are to be tried. Lallemand's method 
of superficial cauterization of the urethra has been adopted 
with success ; but it is a severe measure, and should be appealed 
to only as a last resort. The daily use of a bougie, of moder- 
ate size, sometimes proves sufficient to remove the complaint. 
Sea bathing is usually attended with excellent results, and the 



120 GONORRHCEA AND SYPHILIS. 

dashing of iced water upon the parts is also beneficial. At 
night, camphor and opium will be serviceable. 

Most men who are afflicted with urethral pains are of a 
highly nervous temperament, and require to have the mind 
occupied in some agreeable pursuit, which will tend in no 
small degree to promote a cure of the local difficulty. 



CHAPTER XL 

SPERMATORRHEA. 

The term spermatorrhoea, as employed by most medical 
writers, and as understood by medical scholars, has been 
brought to signify involuntary emissions of seminal fluid, re- 
curring at sufficiently frequent intervals to derange the general 
health. According to Lallemand, however, all excessive gener- 
ative secretions are to be regarded as spermatorrhoea, in what- 
ever manner they may take place, and whether they have 
infringed upon the integrity of the system or not. This sig- 
nification and use of the word is convenient, and is applicable 
to all cases that present themselves for treatment. 

Some individuals listen to the note of alarm at an early 
period, and the first morbid phenomena of the kind now 
under consideration are viewed by them with a just apprehen- 
sion ; and, in anticipation of a train of mental and physical 
evils of direful import, they have the discretion to make known 
their condition to some medical adviser, and to receive from him 
words of salutary admonition and counsel, and thus escape im- 
pending ruin. 

Involuntary discharges of the spermatic substance happen to 
a majority of the male sex from the time of puberty to old age, 
when it ceases to be elaborated. The most continent and pure- 
minded men occasionally find themselves subject to erotic 
dreams during which the event here alluded to takes place. 
Sometimes emissions occur without the coincidence of lascivious 
dreams, — at least, the individual is not conscious of them when 
he awakes ; and he is surprised to find that the spermatic prod- 
uct has escaped while his faculties have been wrapped in pro- 
found sleep. These remarks are applicable to those that are 
in a state of wedlock as well as to those who are not, although 
to the latter they are particularly pertinent. They are intro- 
duced here, not because such infrequent seminal evacuations 
11 (121) 



122 GONORRHCEA AND SYPHILIS. 

really amount to disease, requiring medical prescriptions or 
surgical attentions, but because we occasionally meet with men 
of good intellect and high moral worth and refinement who in 
consequence of this accident, suffer much mental distress 
amounting to profound melancholy. These cases demand both 
moral and medical treatment, and should enlist our best efforts. 
Some men affect great indifference and even aversion to indi- 
viduals who are in a suffering condition from the disease under 
consideration. Such patients, although they may be reaping 
the rewards of their own folly, are, nevertheless, the very ones 
who have special need of correct counsel, and are, for the most 
part, in just the frame of mind to appreciate a word fitly spoken 
by a kind-hearted, judicious medical man. They require skil- 
ful management also, and, if driven from the consulting-office 
of the regular physician, will unwittingly place themselves in 
dangerous hands rather than suffer on alone. " It has always 
appeared strange to me," writes Mr. Milton, " that this affection 
should remain abandoned by the profession to a few solitary 
specialists, and for the benefit of the vile harpies who prey on 
this class of victims. Surgery, which has wrested so much 
from the hands of empiricism and ignorance, seems disposed to 
yield up this, as if it were debatable land, to chance, philosophy, 
utter neglect, or quackery." Mr. Curling holds similar views, 
as in the following sentence : " Medical men are too apt to treat 
the complaints of such patients lightly, making no efforts to 
allay their anxiety, — a course which often leads them to apply 
for aid in illegitimate quarters, and to become the victims of 
unprincipled men." 

I shall never forget the case of an estimable young gentleman 
who consulted me a few years ago for what he called seminal 
weakness. He had completed his collegiate education, and was 
engaged in a professional course of study at a higher institution 
remote from the city. His head was so filled with a wild delu- 
sion in regard to his procreative system, that his ability for in- 
tellectual employment was seriously impaired, and he was every 
way miserable. He told a doleful story, the sum of which was, 
that his present state was the result of " chiromania" or solitary 
vice, of which in former years he had been guilty. He was 
familiar with various trashy books on the evils arising from the 



SPERMATORRHOEA. 123 

practice, and was fearful that he had so far enfeebled his intel- 
lectual and physical energies that he should not be fit for any- 
thing in future life unless he could obtain speedy help. He 
was of a slender figure, dark complexion, pale and dejected, 
and his countenance was the model of despair. He complained 
of sundry anomalous feelings in the urino-genital apparatus, 
thought the testicular organs and their corporeal forces were 
gradually diminishing, and believed that they would soon en- 
tirely waste away. His appetite was poor, bowels sluggish, sleep 
irregular and unrefreshing ; he had headache and involuntary 
seminal emissions about once in the week. He had come to 
Boston as his city of refuge. It was apparent that the trouble 
in this case was chiefly mental, and that to dispel the hallucina- 
tion which haunted his mind was the principal work to be done. 
He was assured that all was right and safe within the scrotum, 
and that the nocturnal accidents were not sufficiently frequent 
to require any special medical treatment. The plan proposed 
was this : A generous diet, bathing in cold water, and drink a 
bottle of Congress Spring water every morning, exercise in the 
open air in all good weather, read no more pseudo-physiological 
books ; early to bed, and early to rise. He was advised, in 
short, to pursue a course that should combine the advantages 
of recreation and the appliances of health. The patient gained 
in appetite and flesh ; the material functions of the system be- 
came natural ; despondency soon gave place to hope ; and, 
after a sojourn in the city of a few weeks, he returned into 
the country with unembarrassed capacity for study. In a few 
months he was called to fill a position in a literary seminary, 
where he still remains, distinguished as a man of letters and 
influence. 

Causes. — One of the most prolific sources of this derange- 
ment of the sexual system is to be found in masturbation. 
This habit is usually formed at an early age, and while the boy 
is attending school. He is generally induced by older boys to 
resort to titillation simply as an affair of sensual gratification, 
without having the slightest idea of the terrible consequences 
which it may entail upon his physical and mental constitution.- 
The precocious and fascinating excitement once experienced, 
and its repetition invited by the contagion of bad example, the 



124 GONORRHOEA AND SYPHILIS. 

lad soon surrenders himself to a frequent indulgence of the all- 
absorbing and fatal propensity, until morbid symptoms, of vari- 
ous kinds and degrees of severity, are induced. The idea of 
self-abuse haunts him wherever he goes and in whatever he is 
engaged. He loses his ability to resist the promptings of the 
baneful passion, and seeks every opportunity to reproduce the 
pleasurable sensations. The constant draughts made upon the 
nervous energies, bring exhaustion and irritability upon the 
whole corporeal organization ; and it is not long before the 
ensnared victim exhibits mournful evidence of declining health, 
as a matter of course. The brain is usually the first organ to 
give indications of disturbance originating in the debasing habit. 
Among the injurious effects exhibited from day to day, may be 
mentioned lassitude, dejection, failure of appetite, and of mus- 
cular vigor. Sometimes the 'boy becomes petulant and exceed- 
ingly irascible ; and the impulse of temper is occasionally so 
intense that he is exhausted from its indulgence, and the admin- 
istration of stimulants is required to relieve the serious depres- 
sion into which he has fallen. In other instances, more frequent 
than the above, the mind sinks into an absolutely stupid condi- 
tion, which gets a firm hold, and he has neither the disposition 
nor ability to engage in the customary sports and other innocent 
employments of his age ; his sleep is broken, he becomes pallid 
and wastes away into a state of marasmus. In some instances, 
violent palpitations of the heart come on suddenly, threatening 
almost instant death ; or epileptic convulsions and idiocy ensue, 
unless the toils which hold the infatuated victims in their em- 
brace are effectually destroyed. 

Derangements of the system, analogous to those which are 
seen in the male sex as a consequence of masturbation, are 
also observable in females who are the subjects of nympho- 
mania ; and these morbid conditions, as physiologists have long 
ago announced, and as daily observation confirms, are induced 
by over-taxing and exhausting the energies of the entire ner- 
vous fabric ; and not because of any waste of spermatic fluid, 
for this is impossible. " The high degree of nervous excite- 
ment," says Carpenter, " which the act of coition involves, pro- 
duces a subsequent depression of corresponding amount, and the 
too frequent repetition of it is productive of consequences very 
injurious to the general health. This is still more the case with 



SPERMATORRHOEA. 125 

the solitary indulgence which (it is feared) is practised by too 
many youths." 

In adult life many causes are sufficient to excite spermator- 
rhoea, especially in individuals endowed with a peculiarly deli- 
cate constitution or an excitable temperament. In these persons, 
the vesiculae seminales acquire the habit of contracting them- 
selves under the influence of excitement less energetic than 
usual, and quite abnormally so. A distended bladder, a bed 
too warm or too soft, lying on the back, warm or stimulating 
drinks, etc., provoke involuntary emissions more readily than 
they ought. The intimate and reciprocal relations between the 
vesiculse seminales and the brain, induce lascivious dreams, les 
plus desordonnes, under the slightest direct or indirect excite- 
ment of the genital organs, and inevitable pollutions from the 
reproduction of all the ideas which are connected with those of 
generation.* Fsecal accumulations in the rectum, and the 
presence of ascarides are to be reckoned among the mechanical 
causes that occasionally give origin to this disease. A varicose 
state of the hsemorrhoidal veins, by exciting disturbance of the 
adjacent parts, will sometimes create undue activity in the sem- 
inal apparatus, and preternatural secretion of the spermatic 
fluid takes place. Pruritus ani is another abnormal circum- 
stance, which, in some individuals, exerts an influence in stim- 
ulating the function of the generative organs to an inordinate 
degree. Other morbid conditions about the anal region may 
exist, and operate as excitants of frequent erections and noc- 
turnal emissions. An inflammatory state of the urethra, whether 
arising from gonorrhoea or otherwise, is one of the most frequent 
causes of the malady under consideration. The inflammatory 
action, commencing in the mucous membrane of the canal, 
extends to the contiguous structures, as the prostate gland, 
vesiculas seminales, and perhaps even to the epididymis and 
testes. Inflammation or irritation of the bladder may also be 
mentioned as now and then giving rise to spermatorrhoea. 
Dalliance with women, and inordinate indulgence in the ven- 
ereal act, are fruitful causes of the complaint. In illustration 
of this last sentence I must here introduce a remarkable 

Case. — I once knew a married man, who was obliged to 

* Vide Lallemand, vol. ii., page 337. 
11* 



126 GONORRHOEA AND SYPHILIS. 

maintain an unceasing warfare against his voluptuous propen- 
sities, or rather, I should say, his sensuous desires were con- 
stantly goading him to commit the venereal act. He had a tall, 
slender, gaunt frame, was well fenced in with bones, but was 
far from being robust. The conformation of his head was 
thought, by some, to afford an illustration of the theory of 
Spurzheim, that the cerebellum is the organ of sexual impulses ; 
and I well remember that the disciples of this German phil- 
osopher were wont to cite the singular cranial development and 
the well-known corresponding mental peculiarities of the man 
who is the subject of this narration, as lending support to the 
principles of phrenology. He was looked upon as the incarna- 
tion of lust, and, like the moth of the silk-worm, he died a 
martyr to his ruling passion. He held a fair standing among 
certain classes of the community, although as to his faithful 
adherence to the marital pledge, the birds of the air sometimes 
carried news. So far as related to his wife, it is certain that he 
had but little control over his venereal desires, or over the 
excessive indulgence thereof. So insane was he at one period, 
that he could not so much as take her hand, or sit on the same 
sofa with her, without being overtaken by the surges of passion, 
and experiencing all the phenomena that attend the complete 
congress of the sexes. These facts were communicated by the 
patient to several medical gentlemen, whom he consulted occa- 
sionally in reference to the exuberance of his animal feelings, 
the gratifications of which he foresaw would ultimately sap the 
vital organs, and bring him to an ignoble grave. His forebod- 
ings were verified in the meridian of life. His insatiable appe- 
tite was destroyed only by the hand of death. 

A great difference obtains in different constitutions in regard 
to the consequences exerted upon the system by inordinate 
indulgence in venereal pleasures. Lallemand says : " I have 
met with men who have given themselves up early in life to the 
greatest abuses of masturbation, and who have subsequently had 
many mistresses at. the same time, and who, in spite of such a 
mode of life, have been capable of continuing it at sixty years 
of age, without their health suffering. I have seen others the 
victims of most obstinate nocturnal pollutions, following the 
slightest errors of their youth. These differences do not, by any 



SPERMATORRHOEA. 1 27 

means coexist in a constant manner with those outward charac- 
ters, which announce the predominance of one of the elements 
entering into the composition of all organs, — still less with the 
development of the frame or muscular system. Thus in the 
sanguine, lymphatic, or nervous temperament, with a robust or 
delicate constitution, the usual organs may present all the 
varieties of volume, power, and ability." 

The virile power in the male is not usually established until 
the age of fourteen or sixteen years. Under the influence of 
excitement, the seminal glands may at an earlier period secrete 
a viscous fluid not containing spermatozoa. In some cases, 
however, the specific changes which betoken, unequivocally, the 
advent of puberty, are well pronounced in boys of a few years 
old. An instance of sexual precocity in a boy of six years of 
age came under my observation a few years since. The organs 
of generation began to exhibit unusual development as early as 
the eighteenth month. At the age of four years, the voice was 
on the base key ; at five, the hair began to grow on the pubes, 
and at six the physical organs had attained the Usual adult size, 
and the child frequently gave evidence of strong sexual instincts. 
He was the son of a respectable physician, and was in all par- 
ticulars well tutored. 

The generative power may continue, if not abused, during a 
very long period. Undoubted instances of virility at the age of 
one hundred years are on record ; but in these cases the general 
bodily vigor was preserved in a remarkable manner. The 
ordinary rule seems to be, that sexual power is not retained by 
the male to any considerable extent beyond the age of sixty or 
sixty-five years. 

Individuals who are suffering, either in reality or in imagina- 
tion, from an abnormal condition of any portion of the genera- 
tive circle, not infrequently propound to the physician questions 
more or less related to the foregoing facts, which, although more 
strictly belonging to the province of physiology, are not out of 
place, it is believed, in the position assigned them in connection 
with the main subject of tins chapter. Other facts, akin to those 
here introduced, might be presented, but their multiplication 
would scarcely increase the practical value of these pages. 

Lallemand made a post mortem examination in two severe 
and complicated cases of spermatorrhoea, in which the patients 



128 GONORRHOEA AND SYPHILIS. 

labored under symptoms of cerebral congestion before death. 
Curling states that he has in one instance had an opportunity to 
dissect the parts affected by the complaint, in which the patient 
was comatose for several hours previous to dissolution. In all 
three of the cases which are here alluded to, the morbid appear- 
ances were of the same character. The mucous membrane of 
the prostatic part of the urethra was swollen and injected. The 
prostate was nearly destroyed and converted into a multilocular 
abscess, or a number of alveoli or cells communicating with each 
other, and the diseased mucous membrane covering it was 
riddled with holes formed by an enlargement of the original 
orifices of the gland, through which pus or altered secretions 
escaped on pressing the prostate. One or both vesiculse semi- 
nales were infiltrated with pus, and their walls thickened by 
inflammation. The orifices of the ejaculatory canals were en- 
larged and abraded. When the prostate is affected, slight pain 
is occasioned by pressing upon it through the rectum, and there 
is usually a discharge from the urethra when the patient is at 
stool.* In protracted cases, there is irritation and chronic 
inflammation of the posterior portion of the urethra. The 
introduction of the catheter gives pain, the patient retains the 
urine with difficulty, and it is sometimes tinged with blood. 
This morbid condition of the canal tends to excite seminal dis- 
charges, to keep alive a train of lascivious desires, and to cause 
the patient's mind to be occupied with imaginary scenes of sen- 
sual gratification, to the exclusion of almost every other 
subject. 

Treatment of Spermatorrhea. — If we could rely with 
confidence on the representations made by the patient relative 
to the facts in his case, we should, as medical advisers, experi- 
ence less difficulty than we now do in directing the proper 
course of treatment. But, unfortunately for the parties con- 
cerned, it often requires the ingenuity of the most expert tacti- 
cian to winnow the truth from error. The patient does not 
intentionally aim to misrepresent or deceive ; nevertheless, if 
allowed to tell his own story without interruption, he is prone 
to bring forward all manner of vagaries ; and we feel compelled 

* Curling on the Testis, p. 329. 



SPERMATORRHEA. 129 

to regard his statements with many grains of caution and doubt. 
Few men who are, or who fancy they are, suffering from sper- 
matorrhoea, are really competent to give a correct account of 
their symptoms. They generally view things through a false 
medium. They are full of fears and anticipations of various 
kinds which impair their normal mental vision. A young man, 
who had for many years indulged in masturbation, called on me 
one warm summer's morning, and reported that his health had 
been for some time declining in consequence of the habit. His 
ability both for physical and mental exertion was much en- 
feebled ; he was nervous and hypochondriacal, and disinclined 
to go into company. He complained of a multitude of troubles, 
such as pains and soreness in the urethra, bladder, kidneys, 
scrotum, perinaeum, etc., and stated that for several weeks the 
semen had passed from him almost constantly, especially during 
the day. While he was asleep at night, seminal emissions occur- 
red about twice in the week. During his call at my office he 
occupied a sofa, and while relating his case, he assured me that 
he could perceive the spermatic fluid escaping and moistening 
his trowsers and making him feel very uncomfortable. I ex- 
amined the parts ; they were bedewed with the natural product 
of the sudoriferous and sebaceous apparatus of the integument, 
and nothing else. This moisture the patient took to be the 
seminal fluid escaping from the testicles through the scrotal 
tunics and spreading upon the external surface ; and this was 
what he meant by his seminal weakness. An exploration of the 
urethra with a catheter showed that this canal was in a healthy 
state, so far as one could judge from such an examination. 
Pressure along the perinasum gave no evidence of disease. The 
young man was convinced that his difficulties were imaginary. 
I counselled him to correct his habits ; and he took his leave. 

I am inclined to the belief that many cases of supposed 
spermatorrhoea exist for every true case.- I have seen not a 
few spurious instances, and but seldom those that were real and 
requiring medical treatment. I must here cite from Ricord, 
than whom no man has a better claim to be heard on this 
subject : " I have had an opportunity to examine a very large 
number of patients or hypochondriacs, and most of them, I find, 
have only discharges of mucus entirely free from animalcules 
and other characteristics of the semen. I know that the con- 



130 GONORRHOEA AND SYPHILIS. 

trary may have been observed in many cases ; but has there not 
been a little exaggeration ? " 

Let us now suppose a simple case of spermatorrhoea. The 
accident constituting the disease happens at irregular intervals ; 
sometimes, once every night ; in other instances, oftener. This 
state of things usually continues for a few months before the 
patient begins to realize that his health is declining. For a 
time, a sense of modesty or shame prevents him from making 
known his complaint, but as its debilitating effects continue, and 
perhaps accumulate, the system sustains itself with less ability, 
the symptoms gradually augment in violence, and an increasing 
apprehension of danger at length drives the victim to the physi- 
cian. The first thing to be done with reference to treatment, is, 
to ascertain, as far as practicable, the actual condition of the 
urino-genital system. In ordinary cases, a careful examination 
will convince the practitioner that no organic change has taken 
place. The urethra, prostate, bladder, and vesiculse seminales, 
give no evidence of anatomical lesion. In some of these organs 
there exists a morbid irritability, and nothing more. It is en- 
couraging and gratifying to the medical attendant, and should 
be to the patient, that no structural disease has occurred. The 
excessive irritability of the parts is, however, in some instances, 
no trifling circumstance to deal with. Although not the origin 
of the spermatorrhoea, it now acts as the exciting agency of the 
accident ; and the hope of preventing this must rest on the 
removal of the local irritability. Moral hygienic regimen must be 
associated with physical means. Both classes of remedies, psy- 
chological and pharmaceutical, are equally and properly within 
the limits of our domain ; and the one, as well as the other, 
should be summoned to our assistance. No two patients are 
precisely alike. Every case must, therefore, be managed accord- 
ing to its own peculiarities and merits ; and in the treatment of 
the causes, as well as'in the treatment of the symptoms of the 
disorder, the medical attendant will do well to gain an insight 
into the mental constitution, the peculiar habits of thought, the 
personality of the patient. To carry out a definite and judicious 
plan of remedial dietetics and prophylactics for the mind, is as 
essential as it is to recruit the strength and energy of the phys- 
ical system through the combined agency of salubrious air, 
cold ablutions, bodily exercise, and other restorative and 



SPERMATORRHOEA. 131 

hygienic measures. If the patient still indulge in his indiscre- 
tion, this must be abandoned. Self-control in this particular is 
a sine qua non as a means of cure, and will constitute the true 
moral asgis of health in the future. Having gained his con- 
fidence, the physician may safely presume that the right moment 
has come to aim an effectual blow against the all-absorbing 
thought that preys upon the patient's mind ; and he may ex- 
press his rebuke, in a kind but decided manner, of the practice 
of self-abuse. Let him be told that this baneful habit, if not 
relinquished, will surely plunge him into the abyss of destruc- 
tion, and that no efforts put forth by the medical man can save 
him. It is sometimes difficult to detect the practice of tins 
solitary vice. The physician may be morally certain of the fact, 
from the character of the symptoms ; and yet the young man 
may stoutly deny it. Dr. Kriner, who published some extraor- 
dinary cases a few years since, has given certain diagnostic 
marks, which are not unworthy of note. The eye is " lack- 
lustre," hollow, watery, without expression, red at the edges, 
with a surrounding circle of blue. The look is unsettled, 
timid; and the individual cannot bear the steadfast gaze of 
another person, a circumstance that is very characteristic. The 
sight is troubled or diminished. There is great lassitude, with- 
out pain, in the limbs, and especially about the loins and 
sacrum ; inaptitude for mental or corporeal exertion ; great 
depression of spirits, and a variety of other symptoms of func- 
tional disturbance of the central organ of circulation, the 
stomach, and other digestive organs; nervous cerebral disturb 
ance, etc. " The disgusting nature of the subject," says the 
Medico Chirurgical Review, " has prevented English writers 
from any description or investigation of the phenomena ; but 
we are well convinced from many cases which have presented 
themselves to our observation, and where the cause has been 
voluntarily confessed or unexpectedly drawn forth, that a great 
number of cardiac affections, as well as anomalous symptoms of 
disorder in other parts of the system, are owing to this destruc- 
tive vice. We have, therefore, though reluctantly, been in- 
duced to draw the attention of our brethren to this melancholy 
item in the list of human failings, because it is, assuredly, a 
prolific source of misery, nay, of death." * 

*New Series, No. 17. 



132 GONORRHOEA AND SYPHILIS. 

If any symptoms of dyspepsia exist, care in the use of suita- 
ble diet, and in regulating any abnormal condition of the ali- 
mentary canal, should be a prominent feature in the treatment. 
Very many persons who are severely troubled with spermator- 
rhoea complain that their food does not set well on their stom- 
ach ; they have gastric or intestinal pains, flatulence, and other 
discomforts of the digestive organs, which should be rectified 
by careful attention to hygienic measures. In this way not a 
little can be accomplished in improving their physical condition. 
A judicious plan of diet and exercise is scarcely subordinate in 
importance to the use of pharmaceutical remedies. Tobacco, 
in all its forms, should be interdicted. Wine and porter may 
be permitted in moderation. They will serve as good tonics, 
and will prevent the system from being completely exhausted. 
The patient should avoid books of a frivolous and imaginative 
description ; also theatres, operas, and all places of idle mid 
fashionable resort ; but, if possible, means should be devised by 
which his mind can be actively engaged in some useful occupa- 
tion. Intellectual culture, where it can be pursued, is one of 
the surest methods of placing the invalid upon advantageous 
ground. Were circumstances convenient, and were I called 
upon to select a branch of study for a young man of suitable 
capacity, I would recommend some department of the natural 
sciences. They are easy of comprehension, seldom fail to enter- 
tain and captivate the individual, create no unhealthy excite- 
ment, are full of instruction, and well calculated to absorb the 
powers of the mind, and thus abstract it from any morbid, 
lascivious train of thought. A young man, once enlisted in 
these pursuits, will find in them a fountain of knowledge which 
he cannot exhaust. Mr. Curling mentions that he once had a 
patient, a man of great intelligence, but without employ- 
ment, whose recovery was essentially promoted by his engaging 
in the study of chemistry, to which he applied himself with 
great zeal. It is well known that the sexual secretions are 
strongly influenced by the condition of the mind. Hence the 
great advantage of having the mental powers actively engrossed 
in some ennobling pursuit, in combination with vigorous corpo- 
real exercise. The effect of such a course is to render less 
active, or even to check altogether, the processes by which the 
spermatic secretion is elaborated. This is a physiological fact, 



SPERMATORRHOEA. 133 

of high moral importance, with those who are of a studious 
turn of mind, although it must be confessed that the number 
of such is very limited, when compared with the large propor- 
tion of directly opposite character. This latter class, however, 
may be brought under the beneficial influence arising from some 
agreeable business or task which they can execute without 
exhausting or greatly fatiguing the physical or mental powers, 
such as gardening, hunting, fishing, a journey, or a short voy- 
age upon the sea. While I have been preparing the contents 
of this page, a young gentleman, — a student, — who has been 
under my treatment for seminal weakness, has called upon me 
to report his condition. He lias spent the last six weeks in the 
country, and has been pleasantly and actively engaged every 
day in various recreations, — mowing, raking, and pitching hay, 
hoeing corn, gardening, fishing, swimming, hunting squirrels, 
and the like. At night, he occupied a large, well-ventilated 
room, lay upon a straw bed, and retired and rose at an early 
hour, without variation. He states that he is now in fine 
health, has had no seminal emissions for four weeks, has gained 
in flesh, his spirits are buoyant ; he is now, in fact, perfectly 
happy. To-morrow he will resume his studies, and, to use his 
own words, uttered in a most animated and joyous style, " he 
is ready for them." If the patient cannot avail himself of any 
of the foregoing pursuits, let him devote a like amount of time 
to gymnastic exercise, verging even on fatigue. If he can be 
induced to resort to these regularly, and be encouraged to per- 
form athletic feats to as great an extent as may be prudent, it 
will be but a short time before a decided amendment will follow. 
Indeed, in all ordinary cases, a cure will be accomplished. 
But if, after a trial of a few weeks, the plans above suggested 
fail to remove the difficulty, it will then be advisable to vesicate 
the perineal integument, or that of the sacrum, by means of 
the cantharidal collodion, as for the cure of gleet. The vesica- 
tory ought to be repeated as soon as the skin recovers from the 
effects of the previous application. I have made repeated trials 
with the collodion. I have never known it to occasion the least 
stranguary, and instead of fearing a frightful exaggeration of 
the spermatorrhoea, as Lallemand seems to have done, the sur- 
geon may look forward with the expectation of the most grati- 
12 



134 GONORRHOEA AND SYPHILIS. 

fying results from its use. No local remedy acts so quickly or 
so surely in checking the complaint. When these measures 
fail to effect a cure, a still more severe local » treatment may be 
employed in chronic, asthenic cases, and that is the insertion 
of a seton in the perinaeum. Mr. Marris Wilson regards this 
as one of the most effectual means, on account of the extensive 
and permanent counter-irritation which is excited.* 

As the mischief we seek to prevent takes place during the 
hours allotted to repose, an important point to be gained is to 
bring the system into a quiescent state, — into a " deep sleep," 
and thus, as almost a matter of course, allay the morbid irrita- 
bility of the sexual organs ; and for this purpose, the exhibi- 
tion of sedatives will be required. The use of opium, at bed- 
time, will, in many individuals, control nervous excitement in 
a satisfactory manner, and will also serve to invigorate the 
exhausted powers of mind and body. Its tendency to render 
the bowels costive and impair the appetite, somewhat invalidates 
its claims in certain cases complicated with dyspepsia. These 
objections may be partially obviated by combining with it hyos- 
cyamus or conium. 

The use of -lupulin, as an anaphrodisiac has lately become a 
popular idea with many experienced men in the profession. It 
may be remarked of it that it is sometimes decidedly efficacious. 
Given in doses ranging from thirty to sixty grains, in sweet- 
ened water, when the patient retires for the night, it frequently 
induces sound sleep, prevents erections, and lessens the chances 
of seminal emissions. Another point of importance may be 
predicated in regard to its properties: it does not appear to 
interfere with the healthy functions, of the stomach or other 
digestive organs. The only inconvenience mentioned by those 
who have taken it is a sense of drowsiness and moderate cere- 
bral plethora for a few hours on the day following its use. It 
certainly acts as a harmless and quite efficient sedative or nar- 
cotic. Another thing in its favor : its employment is compati- 
ble with that of tonics, or almost any other medicinal agent 
which it may be deemed advisable to prescribe. 

The following note from Dr. James Jackson, of this city, 
respecting the use of lupulin, will be read with interest : — 

* On Diseases of the Vesiculae Seminales, p. 89. 



SPERMATORRHOEA. 135 

"Hamilton Place, Nov. 13, 1856. 

" Dear Sir, — I have received your note inquiring what my 
experience has been as to the effects of lupulin in cases of 
spermatorrhoea. In reply, I will remind you of the saying of 
the father of medicine, that experience is encompassed with 
difficulties. The disease in question is one in which this is 
peculiarly true. It consists in involuntary discharges of semen, 
mostly in the night. They may occur every night, and even 
twice and thrice in a night. But many nights may be passed 
without this occurrence. Hence, when a remedy is adminis- 
tered, and they do not take place, you cannot at once decide 
whether the exemption is due to the remedy. I have used this 
article for the disease in question only within two or three 
years. The result of my experience with it is : first, that I 
have not found any inconvenience to arise from it ; second, 
that it has appeared in two cases, both violent as respects the 
constancy of the discharges at the time when the medicine was 
prescribed, to have prevented in a good degree the repetition of 
the discharges. In these two cases I felt assured that the 
reports to me were accurate. In one or two other cases I had 
reason to believe that benefit was derived from the medicine, 
but was not perfectly sure of the accuracy of the reports. In 
more than one case no benefit was derived from the lupulin. 
I do not think that reliance can be placed on less than one 
drachm for a dose. It should be administered every night for 
two or three weeks, and afterwards according to circumstances. 
I think that my experience justifies me in recommending a 
trial of the remedy, since it is not injurious in any way. But 
at best, it is only to be regarded as producing a respite from 
the disease, allowing a chance for the beneficial use of other 
remedies. Allow me to add, that I think no permanent relief 
can be obtained in bad cases except from matrimony. Illicit 
intercourse is not the same thing. These are points on which 
I do not wish to enlarge. 

" Yours truly, I 

"James Jackson. 

"Dr. S. Durkee." 

The secale cornutum exerts a powerful influence over the 
generative system ; and its use as an anaphrodisiac, in oJd 



136 GONORRHOEA AND SYPHILIS. 

atonic cases, has been attended with signal benefit. In recent 
cases, associated with a sthenic condition of the parts, it does 
not act favorably. The forms in which it can be prescribed 
are a spirituous extract made into pills, and an infusion of the 
powdered kernels with camphor mixture. The latter is the 
most effective. 

R. Secalis Cornuti, , 5 iss. 

Aquae Ferventis, | iv. 

Infunde. 

Dose. — One half, to which may be added two drachms of camphor mix- 
ture, to be taken at bedtime. The ergot should not be continued for any 
great length of time : its protracted use is well known to impair the general 
health. 

In cases of long standing, in which irritation of the prostatic 
portion of the urethra has become a well-marked feature, the 
application of the nitrate of silver sometimes answers a valua- 
ble purpose in removing the irritable and sensitive condition, or 
other lesion that may exist in the urethra, at the orifice of the 
seminal ducts, or in the follicles of the prostate gland. To 
overcome this preternatural sensitiveness and irritability of the 
parts, and thus break the chain of morbid phenomena, is an 
important achievement ; and it is claimed by the advocates of 
Lallemand's plan, that the nitrate will accomplish this work, 
and it is admitted that in some cases its action is perfectly ef- 
fectual. But the operation with the porte* caustique is extremely 
painful, and also hazardous ; it has not the merit of uniform 
success, and it does not supersede the necessity of other meas- 
ures. It sometimes gives occasion for their most energetic use, 
for it is exceedingly apt to provoke a high degree of inflamma- 
tion, and there is no calculating where it may stop, or what 
final mischief it may do. The application of caustic gently 
employed, and not allowed to remain in contact with the parts 
for more than a second or two, may be a safe and justifiable 
procedure. It has been thus used many times without any 
unfortunate results. On the contrary, severe retention of urine, 
hemorrhage, and the most excruciating agony, and even stric- 
ture, have been produced by the porte caustique. All these 
terrible effects may follow, without one iota of benefit to the 
malady for the cure of which the caustic is brought into the 



SPERMATORRHOEA. 137 

field of action. It is no more than truth to say that Lalle- 
mand's instrument is now regarded with instinctive horror, and 
as a barbarous weapon ; and its introduction into the urethra 
of any man should not be attempted until all other resources 
of surgery have been appealed to in vain. 

Injections of mucilage, containing one grain of opium and 
two grains of the acetate of lead to the ounce, are often attended 
with good effects, and are worthy of a trial. They are free 
from danger, they give no pain, and may be repeated every 
three or four hours during the day. Water employed as an 
injection has a soothing effect, and is applicable to nearly all 
cases. It may be used as warm as can be borne, and may be 
repeated many times in the day. Let it reach the whole length 
of the urethra. As valuable adjuncts, small doses of cubebs 
should be administered internally. The inunction of veratrine 
and belladonna upon the perinseum will sometimes be of service 
in relieving pain, and allaying the irritable condition of the 
organs : — 

R. Unguenti Belladonna?, . § ss. 

Veratria?, 9ss. M. 

In some instances, the patient suffers from an irritable state 
of the kidneys and bladder, accompanied with constant drag- 
ging pain. Under such circumstances, a combination of the 
tincture of hyoscyamus and camphor will form a good sedative, 
which may be administered at bedtime : — 

R. Mucilaginis Acacise, % ss. 

Tincturse Hyoscyami, § j. 

Misturse Camphorae, §.ij. M. 

Dose. — Three drachms in toast-water or rice-water. This may be repeated 
in two hours if the desired relief be not realized from the first dose. 

The bromide of potassium exerts a powerful sedative effect 
upon the genital organs ; and it has been successfully adminis- 
tered in severe cases of spermatorrhoea, in doses of fifteen to 
thirty grains, in mucilage.* 

* The observations of Thielmann and Pfaffer confirm the above statement 
relative to the therapeutic action of the bromide. 
12* 



138 GONORRHOEA AND SYPHILIS. 

Quinine, dilute nitric acid, the tincture of muriate of iron, 
the carbonate of ammonia, and the carbonate of potash are all 
medicinal agents of well-known properties and utility, and can 
be variously employed as the condition of the individual may 
suggest. If the general health should improve under any 
course of treatment, let that treatment be continued. 

While in all forms of spermatorrhoea the most important 
remedial indication has reference to the amelioration and cure 
of the constitutional effects of the complaint as displayed both 
in the physical and the mental fabric, the medical attendant 
will take good care, first of all, to discover, if possible, and 
remove, the primary cause. 

There is great liability to a return of the malady even after 
the organs and the constitution generally have been restored to 
a sound state, and great watchfulness will be requisite to keep 
the patient from falling into a relapse. If there be reason to 
suppose that he is capable of successfully engaging in sexual 
intercourse, — if he be of suitable age to marry, and if other 
circumstances converge to this point, — then he may with great 
propriety be advised to assume such relations ; for here he will 
find the most efficient remedy, and will be secure, if he can be 
anywhere, from those diabolical influences and temptations 
which gave rise to his disease. It so happens, however, that a 
majority of young men who are subject to frequent involuntary 
spermatic discharges are not of suitable age, nor in proper cir- 
cumstances, to take upon themselves the responsibilities of mat- 
rimonial life. 

Castration. — Spermatorrhoea may be kept up by a diseased 
condition of the kidneys, the bladder, the prostate gland, or 
urethra. In such instances the testicles are not the offending 
organs ; and if the individual were to be deprived of these 
glands, as a curative measure, success would not attend the 
operation. Mr. Wilson relates an extraordinary instance in 
which Sir Astley Cooper was induced to remove one testicle. 
The operation brought no relief. Repeated cauterization of the 
urethra was then tried, but in vain. Next, the remaining tes- 
ticle was removed, but with no alleviation of symptoms. Erec- 
tions and emissions, both nocturnal and diurnal, returned as 
soon as the patient recovered from the inflammation that fol- 



SPERMATORRHOEA 139 

lowed the operations. The fluid ejected was less in quantity 
and altered in quality from what it was before castration. A 
cure was finally accomplished by establishing issues with potassa 
fusa introduced beneath the integument midway between the 
anus and commencement of the scrotum. In this case, it was 
at last supposed that the disease was located in the vesiculae 
seminales. The patient was a medical man. For several years 
he had been the victim of self-abuse, brought on by bad exam- 
ple at school, and to this practice he attributed his infirmity. 



CHAPTER XII. 

GONORRHEAL OPHTHALMIA. 

This affection is of rare occurrence. Some surgeons who 
have seen much of gonorrhoea and its consequences, have had 
no instances of the frightful forms of the malady mentioned in 
standard works, and they regard as almost fabulous the vivid 
descriptions of cases reported from time to time in the medical 
periodicals of the day. It seems a little singular that no edition 
of Hunter contains any allusion to the malady until we come 
to that by Ricord, who has inserted a brief chapter on the sub- 
ject from his own pen. Mr. Johnson in his work on gonor- 
rhoea, gives us to understand that the popular idea relating to 
the affection is in most instances a humbug ; such calamitous 
results as are detailed in some surgical treatises having never 
been seen in his practice. Dr. Vetch, also, a distinguished 
ophthalmic surgeon, is skeptical on the same subject. He 
recognizes contagion as a source of the disease ; but denies 
that the matter taken from the urethra of the infected patient 
can produce any effect in the same individual. The incorrect- 
ness of this theory, however, is amply demonstrated by the 
experience of other surgeons. Some years ago, and almost 
simultaneously, two cases, which are in point, occurred in the 
practice of Mr. Travers at St. Thomas' Hospital in London. 
In one of these, purulent ophthalmia commenced seven days 
after a gonorrhoeal discharge from the urethra. The inocu- 
lation happened thus : While the man was employed in 
breaking stones, and shortly after micturition, a particle of 
stone struck his left eye, which led him immediately to rub it 
with his fingers. Pain and swelling of the eyelids took place 
immediately, and the inflammation attained to such a degree 
as to destroy all vision in that eye in the course of an hour. 
He experienced very severe pain in the eyeball, the temples 
and occipital region, and also that sensation of animate, ex- 

(140) 



GOXORRHCEAL OPHTHALMIA. 141 

traneous particles on the conjunctiva, so frequently observed 
in inflammation of that membrane. The cornea sloughed away 
in a few days, and the lens and a portion of the vitreous humor 
escaped. In the second case, virulent gonorrhceal ophthalmia 
was distinctly traced to the local application of matter from 
the urethra. Both eyes were implicated, and in a brief period 
total blindness followed. Mr. Travers states that in all cases 
of gonorrhceal ophthalmia that ever came under his notice, the 
disease had its origin in the contact of matter transferred from 
the urethra to the eye. Surgeons almost universally regard 
inoculation of gonorrhceal pus as the most frequent cause of 
the ophthalmia. Cases have been known in which the com- 
plaint has been caused by the patient washing his eyes in his 
urine as a eollyrium, whilst suffering from blennorrhagia. It 
is, on the other hand, certain, that in thousands of instances, 
persons who are careless in their habits put the gonorrhceal 
matter in direct contact with the mucous membrane of the eyes 
with impunity. They rub and scratch the lids without any 
regard to the fact that the fingers may be coated with the 
virus, but no harm ensues ; and direct experiments of inocu- 
lating the conjunctiva with the morbific urethral discharge 
have failed to induce ill effects. Patients are also constantly 
running their fingers within the nasal passages, and picking 
the mucous surface, while, from the very nature of things, the 
ends of their fingers are smeared with the gonorrhceal dis- 
charge. And yet not more than one or two cases of nasal 
blennorrhagia have come to my knowledge. On the contrary, 
students, who- have officiated as dressers in gonorrhceal cases, 
and washerwomen, who have had charge of the linen of such 
individuals, have frequently been attacked, in a sudden manner, 
with the most violent and malignant form of the complaint. 
In the generality of cases, it is developed only in one eye at a 
time ; if it invades the second eye, it is after a short interval. 
In nine instances out of fourteen, recorded by Mr. Lawrence, 
only one eye was diseased. In the most violent cases, the 
complaint bursts forth with extraordinary fury, advances with 
rapid strides, and entirely destroys the sight at an early period. 
Inflammation, tumefaction, and chemosis of the conjunctiva 
take place, and the lids are soon involved in acute inflammation. 
The chemosis becomes phlegmonous, forms a close band around 



142 GONORRHOEA AND SYPHILIS. 

the cornea, which is concealed and constricted, and is soon af- 
fected with deep ulcerations and sloughing ; the lens drops out, 
the vitreous humor follows, the iris protrudes, and the remain- 
ing portions of the eye collapse within the socket, where they 
are deeply buried by the closing up of the lids. All this is the 
work of a few days. 

The true etiology of gonorrhoeal ophthalmia is still the 
theme of discordant speculations and opinions. Some of these 
views are better calculated to bewilder than to instruct. The 
means of propagation of the virus remain, to some extent 
at least, a sealed problem, and as such they must continue, 
until pathological science shall have made greater advances 
than it has yet done. I shall not attempt the fruitless task of 
examining all the various theories that have been maintained 
by writers occupying different stand-points of observation. 
Experience and common sense attribute the complaint chiefly 
to the inoculation of the poison derived from the urethra, or 
from an eye already involved in the disease. So long as the 
urethra yields a purulent discharge, be it a longer or a shorter 
time from the commencement of the blennorrhagia, it is doubt- 
less capable of generating an ocular blennorrhagia also. But 
even this idea is not without its difficulties ; for when we con- 
sider that in the vast majority of instances in which the ure- 
thral pus is brought in contact with the eyes, no morbid action 
follows, we see that disease is the exception rather than the 
rule. The ophthalmia is confined almost entirely to the male 
sex. But very few well-marked instances have ever been seen 
in female subjects. 

Besides contagion, another mode by which blennorrhagic 
ophthalmia is believed to arise, is found in what is called 
metastasis ; a term, the precise meaning of which is not fully 
agreed upon. In this form of the malady, it is supposed the 
patient suffers in a manner analogous to those successive at- 
tacks which are observed in rheumatism and gout ; * and yet 
in the two latter diseases it is very probable that the vital 
fluid is in an abnormal state, so that any proof or argument 

* " In these complaints there is every thing to show a morbid condition of the 
blood, which is surcharged with compounds of carbon and of nitrogen, and the 
local action is the expression and effect of constitutional deterioration." — John- 
son on Gonorrhoea. See also Simon's Chemistry of Man, page 225. 



GONORRHEAL OPHTHALMIA. 143 

derived from the doctrine of analogy, amounts to little or 
nothing. Perhaps as satisfactory an example as any of what 
is understood by metastatic action, is to be found in cases of 
cynanche parotidea. Here the inflammation, originating or 
set up in one gland, is translated to another, and the sufferings 
of the testes in the male, or of the mammae in the female, are 
believed to take place in consequence of some mysterious oc- 
cult agency through the medium of the nervous tissue. And 
now the query suggests itself, can this with any show of rea- 
son be said of blennorrhagic ophthalmia? To me it seems 
that there is not sufficient evidence to sustain the theory of a 
metastatic form of this disease. 

Sir Astley Cooper derived his notions from the statements 
of others ; and was inclined to favor the doctrine of metastasis. 
Ricord inculcates the hypothesis that there are three varieties 
of the affection: the contagious, the metastatic, and the sym- 
pathetic. Speaking of the second form, he says : " Abernethy 
admitted an irritative state in order to explain the develop- 
ment; this is what we understand by metastasis. The origin 
of the term comes from the wandering character of the com- 
plaint; it oscillates, disappearing in one place to reappear in 
another, and in this respect does it not resemble a rheumatic 
affection? Do we not admit metastasis in rheumatism ? " He 
argues, that beyond the possibility of contagion, patients are 
found affected with ocular blennorrhagia following that of 
the urethra; and that such cases are most frequently related 
to some rheumatic symptoms. Acton admits of but two varie- 
ties, one from contagion, the other from metastasis. Mr. 
Graves * is inclined to the belief that a species of severe oph- 
thalmia may be generated through the medium of the consti- 
tution in persons liable to gonorrhceal rheumatism or arthritis. 
Mr. Lawrence advocates a similar doctrine. Mr. Walton, re- 
ferring to the origin of the disease, says : " To metastasis has 
it been attributed, and what is stranger still, there is ' gonor- 
rhceal ophthalmia without metastasis or inoculation ' spoken 
of. By this is meant that the gonorrhoea and the ophthalmia 
are one and the same disease, and that without any metastasis 
or inoculation, one passes into the other. I have no faith in 

* Clinical Lectures, 2nd Edition, p. 401. 



144 GONORRHCEA AND SYPHILIS. 

the metastasis ; and as to the last supposed mode or origin of 
the disease, I receive it as a great twaddle." * Mr. Johnson, 
speaking of contagion and of metastasis, tells us that his experi- 
ence induces him to extend a considerable degree of incredulity 
to the ordinary agency of either. His ideas of sympathy are, 
that it means nothing, explains nothing, and implies nothing, 
save that such and such conditions often coexist. In some 
individuals, he believes there exists a constitutional tendency 
to the ophthalmic affection. 

I take pleasure in transferring to these pages the following 
communication from Dr. Henry W. Williams, an eminent oph- 
thalmic surgeon of this city. His views are expressed with 
candor and perspicuity : — 

" I am entirely satisfied that a violent form of inflammation 
usually designated c gonorrhceal ophthalmia,' may result from 
a contact of the urethral discharge with the mucous membrane. 
A few well-attested instances where the disease has been thus 
produced, are worth more than any amount of negative 
evidence ; and that these instances are not infrequent, seems to 
be admitted by most of the authorities on ophthalmic surgery. 
Before citing cases, which have occurred in my own experience, 
I will refer for a moment to the facts which indirectly cor- 
roborate the theory of contagion. Among these may be men- 
tioned the far more frequent occurrence of the disease in men 
than in women ; the different situation of the urethra in the 
female and her different style of dress rendering her far less 
liable to the introduction of the discharge into the eyes ; while, 
if the disease were occasioned by metastasis or sympathy, she 
ought to be equally subject to it. 

" Another proof is found in the limitation of the disease, fts a 
general rule, to one eye, which is not true with regard to other 
forms of severe inflammation of the conjunctiva. The experi- 
ments of Vetch, which have often been cited, were by no means 
conclusive in their character, and if they had been performed in 
a mode which would have given them more value, the proof 
would still have been only negative ; viz., that in those instances 
inoculation did not take place. 

" The same evidence that convinces us that the disease may 

* Medical Times, Nov. 4, 1848. 



GONORRHEAL OPHTHALMIA. 145 

result from contagion, leads to rejection of the theory that it 
ever arises from metastasis or sympathy. Why should we 
assume such an origin upon mere supposition, while we have 
no obvious and sufficient explanation confirmed by facts ? 
Were one of the internal parts of the eye the seat of the dis- 
ease, we might plausibly ascribe it to metastasia ; but the 
morbid phenomena have their origin and seat in the conjunctiva, 
which is exposed to constant danger of inoculation from un- 
cleanly fingers, which have become impregnated whilst examin- 
ing the state of the urethral disease. Were metastasis the 
cause, we might also expect a subsidence of the local urethral 
symptoms, as they were transferred, in greater severity, to the 
eyes ; but such is not the fact. 

" I select a few of the cases which have come under my 
observation : — 

" Case I. — Some six years since, I saw, while making a visit 
to the House of Industry with Dr. Buckingham, the physician 
of the institution, a woman who was acting as one of the hospi- 
tal attendants. After the visit, she washed the speculum which 
had been used in examining a patient with gonorrhoea. Within 
a few hours severe inflammation of the conjunctiva came on, 
and two days afterwards, when next I saw her, the cornea 
had given way in both eyes, the iris protruded, and vision was 
entirely lost. I have never seen a case where the disease 
was more rapid than in this instance ; but one of my friends 
assures me that he has seen the cornea lost in ten hours from 
the appearance of the first symptoms, and other similar cases 
are on record. 

"Case II. — In 1851, I saw, in consultation, a gentleman 
who had a severe attack of ophthalmia, coexistent with gonor- 
rhoea, and where circumstances seemed to fix the moment of 
inoculation of the eye. The cornea was very largely ulcerated, 
and perforation imminent ; but the eye was saved, and vision 
is not much impaired by the opacity forming the cicatrix of the 
ulcer, as the centre of the cornea has become clear. 

" Case III. — About two years since I saw a case similar to 
the last in all its important features. Here the moment of in- 
13 



146 GONORRHCEA AND SYPHILIS. 

troduction of the virus appeared to be definitely fixed. In this 
instance the termination was most favorable, although the symp- 
toms were very severe. Very slight traces remain of ulceration 
of the cornea. 

" Case IV. — A year since I was consulted by a young man 
residing at a distance, who had fixed in his own mind the time 
when inoculation occurred. His physician, however, did not 
believe this. He placed himself for treatment in the care of a 
hydropath and in a few days the eye was destroyed, the 
progress of the disease being favored by the absurd remedies 
made use of. 

" I might add other cases ; but these appear to be sufficient 
to illustrate the views I have brought forward. 

" I am, sir, very respectfully, your obedient servant, 

" Henry W. Williams.'' 

" Dr. Durkee." 

Diagnosis. — One writer affirms that he has found a symptom 
in gonorrhceal ophthalmia, which he regards as extremely valu- 
able in a diagnostic point of view, namely, the existence of a small 
round or oval tumor beneath the skin, peculiarly sensitive to 
the touch, situated in front of the ear of the affected side, and 
consisting of an enlarged lymphatic ganglion. This he terms 
" bubon preauriculaire ; " and as he has met with it in nine 
cases where he was able to trace the disease to direct contact, 
and as he has remarked its absence in some hundred instances 
of purulent ophthalmia, not connected with gonorrhoea, he is 
inclined to look upon it as a symptom pathognomonic of this 
form of the disease.* No other author appears to believe in 
the existence of these pre-aural buboes, and it is very generally 
agreed that so far as relates to mere symptoms, the affection 
has nothing characteristic which may not exist in other purulent 
ophthalmias. If the patient can detect the potential cause, and 
trace it to a coexisting gonorrhoea, as in three of the cases 
related by Dr. Williams, or to contagion derived from a second 
person, that is another thing. The evidence of its specific 
character is complete. Experience sustains the opinion, that, 

* De l'Ophthalmie Gonorrhoique, — Louvain, 1846. — Vide Egan on 
Syphilis, p. 110. 



GONORRHCEAL OPHTHALMIA. 14T 

apart from a knowledge that the disease is received by inocu- 
lation, the physician has no reliable means of diagnosis between 
this complaint and what is called Egyptian ophthalmia, or ca- 
tarrhal ophthalmia. 

Treatment. — From the commencement of the attack, the 
symptoms present various degrees of intensity in different cases, 
and of course the character of the treatment, both local and 
constitutional, must possess a somewhat corresponding variety. 
If the complaint be ushered in with great violence, and the 
patient is sufficiently vigorous, blood may be taken from the 
arm. Lawrence and Erichsen place great reliance upon this 
method of depletion. Cupping, or leeches applied to the 
temples or behind the ears, will be indispensably requisite. 
The frequency of the bleeding must depend upon the urgency 
of the inflammatory action, and upon the powers of endurance 
of the patient. In the most vehement and appalling attacks 
of gonorrhoeal ophthalmia, the largest bleedings have been 
attended with the least success ; and at the present day, blood- 
letting is not carried to any thing like the extent which was 
once considered proper. It is now well understood that inflam- 
matory action of the mucous membranes, especially if attended 
with an increased flow of their secretions, requires a much more 
moderate sanguineous depletion than inflammation set up in 
other tissues. Hence, in diarrhoea, in dysentery, etc., bleeding 
from the arm is now an obsolete idea. 

Saline aperients are preferable to any others. The individual 
should occupy a large room, which should be darkened ; he 
should be confined to the bed, with the head considerably raised, 
and an antiphlogistic regimen must be prescribed and rigidly 
adhered to. Topical means are of primary importance in this 
affection. The eye, if saved at all, will be saved by remedies 
applied directly to it. When, from the history of the case, the 
medical attendant has arrived at a clear conviction that the 
attack proceeds from the virus of urethral blennorrhagia, no 
time should be lost in applying that most active local agent, the 
solid nitrate of silver, to the conjunctiva of both lids. The 
under one should be touched first. It should be everted, and 
the nitrate drawn over the surface so as to whiten it. Before 
the surgeon lets go his hold of the lid, it is to be washed with 



148 GONORRHOEA AND SYPHILIS. 

warm water, by means of a small syringe that will throw a fine 
stream. The upper lid should be subjected to the same treat- 
ment. In ten or twelve hours it may be necessary to repeat 
the application ; meanwhile the eye should be syringed every 
half hour with tepid water, for the purpose of keeping it as free 
as possible from the muco-purulent discharge, which, in a few 
hours from the commencement of the ophthalmic symptoms, 
becomes very abundant, and is a source of constant annoyance. 
The sulphate of copper, in substance, drawn gently over the 
inner surface of the lid, in the same manner as the nitrate of 
silver, is attended with good effect. A solution of the copper 
may also be applied, in some cases, with entire success. Some- 
times it will act favorably, where no benefit is derived from the 
silver. The strength of the cupreous solution may vary from 
two to four grains to the ounce of rose-water, which should be 
applied every eight hours, provided it appears to act favorably. 
During the night, the lids will become agglutinated, unless 
something be done to prevent it. They should, therefore, be 
smeared with rose-ointment. 

In the early stages of the attack, warm opiate fomentations 
will be of service in soothing the inflamed organ ; but, if the 
vascular congestion continue to increase, and the disease be 
complicated with chemosis, warm applications will do injury. 
The lids ought to be kept covered with compresses soaked in 
weak alum-water, two grains to the ounce, or the liquor 
plumbi, in the proportion of one ounce to eight ounces of 
water.* The constant application of ice, secured in a delicate 
linen bag, sometimes acts favorably in checking the high inflam- 
matory action. 

The infiltration of the serous or sanguineous fluid between 
the ocular conjunctiva and sclerotica, and which constitutes the 
chemosis, performs an important part in the work of destruc- 
tion, to which the cornea and other tissues are exposed. The 
entire cornea sloughs away, protrusion of the iris and lens 
takes place, forming staphyloma, and resulting in total loss of 
vision. The late Mr. Tyrrell employed scarification so as to 

* Some surgeons object to lotions containing lead, zinc, etc., on the ground 
that solid particles of the salt employed are sometimes found deposited on the 
inflamed surface, and thus increase the morbid action. They, therefore, pre- 
fer vegetable astringents as topical remedies to the eye. 



GONOKRHCEAL OPHTHALMIA. 149 

radiate from the margin of the cornea. This practice was 
based upon the theory that the cornea perished from strangula- 
tion of its vessels. Whether this idea is purely theoretical, 
having no foundation in fact, has been doubted ; but the advan- 
tage of adopting prompt measures for the removal of the infil- 
trated matter-, does not admit of any question. If the chemosis 
be severe and oedematous, forming a turgid ring around the 
cornea, it should first be excised ; if it be phlegmonous, and 
the curved scissors cannot be advantageously employed, it 
should be scarified. Either procedure will relieve the engorged 
vessels of the overhanging conjunctiva, and will promote the 
favorable action of other remedies. After scarifying or excising 
the membrane, the bleeding may be promoted by warm-water 
fomentations. Excision causes severe suffering, and ether 
ought to be used at the time of the operation, and an opiate 
given afterwards. 

When sloughing of the cornea has commenced, the antiphlo- 
gistic treatment must be abandoned, and a stimulating and 
tonic plan adopted. A solution of alum, six grains to the 
ounce of rain-water, makes a proper collyrium at this crisis. 
The undiluted liquor plumbi diacetatis is also a valuable topical 
remedy. Two or three drops are to be inserted under the lids 
every six hours during the day. It diminishes the secretion 
and the inflammation, and there is no danger of its doing 
injury at any stage of the disease. The nitrate of silver, three 
grains to the ounce of rose-water, may be applied three or four 
times a day, so that the immediate effect of the application may 
not pass away before it is repeated. One or the other of the 
above local applications can be made use of, as the physician 
may choose ; but it would scarcely be good practice to employ 
any two at the same time. Their use must be persevered in 
until the purulent secretion ceases, when the disease may be 
considered as virtually at an end. Care must be taken that none 
of the discharge from the affected organ come in contact with 
the eye of the medical attendant or nurse, as it is contagious, 
and will almost to a certainty reproduce the same disease. 
Instances are recorded in which the attendant's vision has in 
this way been suddenly destroyed. 

The .application of the extract of belladonna around the 
13* 



150 GONORRHCEA AND SYPHILIS. 

orbits or upon the temples should not be omitted. Permanent 
adhesions of some portion of the iris to the capsule of the crys- 
talline lens, or to the inner surface of the cornea, may form in 
consequence of the inflammation ; and the belladonna will be 
the surest means of preventing such an accident. After the 
most violent and dangerous symptoms of the first stage have 
abated, the morbid process occasionally assumes a passive char- 
acter. The disease becomes atonic ; and the most effectual 
mode of treatment will consist in supporting the system by 
generous diet, quinine, and the like. Blisters to the nape of 
the neck will now be proper, although during a high state of 
inflammation they would be prejudicial. As a constant lotion 
during the day, the extract of lead, in the proportion of one 
drachm to three ounces of water, will be useful ; and at night, 
the following ointment should be employed : — 

R. Hydrargyri Ammoniati, gr. vj. 

Oxydi Zinci Impuri Prseparati, 

Boli Armenia?, aa, gr. xviij. 

Unguenti Rosarum, gss. M. 

The concentrated nitric acid will be found an excellent 
remedy in cases of long standing. It may be applied to the 
everted lids by means of a camel's hair pencil, which should 
be made merely damp with the acid, and drawn lightly and 
quickly over the mucous membrane. The lids should then be 
washed in tepid water, by means of a second hair pencil, which 
should be at hand. The acid turns the surface white, like the 
nitrate of silver. It can be used every second or third day. 
In all instances of severe and obstinate character, opiates will 
be demanded throughout the whole course of the disease. The 
patient must have nearly the normal amount of sleep, by some 
means, or he will not progress favorably towards a cure. In 
regard to mercurials, it may be said that their use is not only 
of no advantage, but absolutely detrimental, in the' early stages. 
In the more advanced and chronic period, a blue pill, every 
second or third night, for a few times, and followed next morn- 
ing by a small saline laxative, will usually be beneficial. In 
all mild cases of blennorrhagic disease of the conjunctiva, the 
treatment should also be mild ; and a majority of cases are of 



GONORRHEAL OPHTHALMIA. 151 

this description. An aperient every other day, low diet, half a 
dozen leeches to the temple occasionally, a small blister behind 
the ear, astringent injections or collyria to the eye, exclusion 
from the action of light, warm opiate fomentations repeated 
three or four times each day, the use of belladonna to or near 
the affected organ, embrace about the entire list of remedies 
that we are to rely upon. In conjunction with any or all of 
these, whatever hygienic plan can be practically enforced should 
be put in requisition. 



CHAPTER Xni 

OPHTHALMIA NEONATORUM. 

The direct application of the acrimonious vaginal discharge 
to the eyes of the newly-born infant during parturition, is by 
far the most frequent cause of purulent ophthalmia among this 
class of subjects. The discharge may consist of leucorrhceal 
or gonorrhceal matter. When the disorder is consequent upon 
contagion from the latter, it is of the most inveterate nature. 
Most of the cases that occur are among the low and dissolute, 
and if neglected, as they often are, the morbid action soon 
reaches the cornea, purulent infiltration takes place between its 
laminae, and sloughing, followed by an escape of the humors, 
loss of the lens and of vision, finally ensues. On the other 
hand, if the child be seen by the physician at an early period, 
and the case properly attended to, it will be found, ordinarily, 
to be quite manageable, and recovery will in a short time take 
place. In the crowded wards of a hospital, where it is impos- 
sible for the inmates to have the benefit of pure air and other 
hygienic conditions, pyophthalmia is much more frequently a 
severe and intractable affection than in private practice. 

The conjunctiva of the upper lid is usually more deeply in- 
volved than the other. It is frequently the seat of ulcerations 
when none exist on the lower lid. The malady is visible in 
three or four days after the child is born, sometimes later. The 
lids first swell, and, in a day or two, are glued together by a 
thick, puriform discharge, secreted from the mucous membrane 
of the conjunctiva. In some instances, a transverse, red line 
can be seen on the eyelid before the purulent exudation appears. 
The firm closure of the lids serves to retain the morbid fluid, 
and, as a consequence, they become puffy and sometimes greatly 
distended. The affection is not usually attended with much 

(152) 



OPHTHALMIA NEONATORUM. 153 

pain, unless the child is exposed to a glare of light. This is 
particularly the case as regards the first stage of the attack. 
Infants with their eyes entirely closed in consequence of swelling 
of the lids, accompanied with copious discharge of pus and the 
other ordinary phenomena of the disease, will pass days, or even 
weeks, without manifesting signs of distress from the local affec- 
tion. They nurse with fair appetite, and are much of the time 
in a quiet sleep. In the more advanced stage of the complaint, 
when the inflammatory action extends to the conjunctiva of the 
eyeball and to the cornea, and when the tumefaction of the lids 
has greatly augmented, the sufferings of the child are severe. 
In some cases the swelling of the lids themselves from the serous 
effusion into their cellular texture, is so great that eversion 
occurs when any attempt is made to examine the eye by sep- 
arating the palpebral ; or it will take place by the crying of the 
child, when the whole globe will appear as if pushed forward. 
There is intolerance of light from the very commencement of 
the affection even in its mildest form. In the attempt to open 
the lids, the eyes of the little patient are involuntarily turned 
upward in the socket, so as completely to conceal the cornea 
from view, and the physician has no little difficulty in ascer- 
taining the real condition of this membrane. Sometimes the 
intolerance of light is so great, that when the child opens its 
eyes voluntarily they are instantly closed with violent spasmodic 
action, and the lids are squeezed together with great force, 
attended with a gushing out of the purulent accumulation 
between them. If it be carried near a window, it will frequently 
open and close its eyes twenty times in a minute, in the manner 
here described ; and the process will be accompanied by a sim- 
ultaneous jactitation of the limbs as if affected by a galvanic 
shock, and the only way in which the child can be at rest, is by 
being in a dark place. I have now under treatment a case pre- 
cisely of this kind. The infant is five weeks old ; it weighed 
eleven pounds at birth. It nurses and thrives sufficiently, is 
very fat, and apparently does not suffer pain from the ophthalmia. 
The mother states that she has for several months had blen- 
norrhagia. 

Treatment. — The character and success of the treatment 



154 GONORRHOEA AND SYPHILIS. 

will depend not a little on the time when the physician first sees 
the patient. Should he be called early, a mild course will 
usually suffice to check at once the further progress of the affec- 
tion, and to save the visual organ from serious injury. One of 
the first things to be done is to remove the purulent deposit 
from the eyes. This may usually be accomplished by gently 
washing them in tepid water. 

Sometimes the lids are so firmly adherent that a soft cracker 
poultice must be applied for a few hours. As soon as the lids 
can be separated, mild astringent injections and colly ria should 
be ordered. An injection of one grain of the oxymuriate of 
mercury to eight ounces of distilled water may be used every 
hour during the day. The thick purulent matter may not be 
entirely removed until several repetitions of the injection. It is 
not expedient to attempt too thorough treatment at the first 
trials. The local symptoms might thus be aggravated. As soon 
as the surgeon fairly gains access to the conjunctival mucous 
membrane, the mother or nurse can be instructed how to pro- 
ceed afterwards. A few injections, judiciously employed, will be 
quite certain to bring about a change for the better ; and the 
secretion will soon diminish in quantity. Injections are better 
than mere lotions, provided they are properly given. Topical 
measures are mainly to be relied upon, and in a majority of 
cases satisfactory results will follow.* A weak infusion of cham- 
omile, or a weak decoction of white oak bark, makes a suitable 
injection, and either may be used in alternation with the one 
just mentioned. A solution of the nitrate of silver, in the pro- 
portion of four grains to eight ounces of distilled water, may be 
advantageously applied to the diseased membrane two or three 
times a day. The eyes should be thoroughly cleansed with 
warm water before using the solution, a few drops of which are 
to be inserted at the outer canthus. Alum makes a valuable 
collyrium, three grains to the ounce of soft water ; also, the 
liquor plumbi greatly diluted. The following lotion, due to Mr. 
Wharton Jones, is extensively used in European hospital prac- 

* Mr. Critchett, Surgeon of the Royal London Ophthalmic Hospital, says : 
" Local stimuli should be applied early, often, and thoroughly to the conjunc- 
tival surface in purulent ophthalmia of infants." — Lancet for August , 1854, 



OPHTHALMIA NEONATORUM. 155 

tice for various forms of purulent ophthalmia and chronic con- 
junctivitis : — 

R. Cupri Sulphatis, gr. ij. 

Vini Opii, 5j- 

Aquse Destillatae, 5 vij. M. 

Fiat lotio. It may be applied freely with a soft camel's hair brush three 
times a day. — Association Medical Journal, 1856. 

The following preparation I have employed for several years 
in ordinary cases of the disease under consideration. There is 
no local remedy which I have occasion to regard with more 
favor : — 

R. Hydrargyri Ammoniati, gr. vj. 

Oxydi Zinci Impuri Prseparati, 

Boli Armenia?, aa, gr. xij. 

Unguenti Rosarum, § ss. M. 

The wine of opium constitutes a suitable local remedy in 
chronic cases, after the purulent discharge has nearly ceased. 
The conjunctiva is in a relaxed condition, and the vinous pre- 
paration will serve as a valuable stimulus and anodyne. It 
should be applied to the parts three times a day. Bleeding, 
even by means of leeches, is a practice never required in. these 
cases. Small doses of magnesia, or if the child has a jaundiced 
skin/as sometimes happens, of hydrargyrum cum creta, may be 
ordered every second or third day. If much febrile action be 
present, a few drops of the dulcified spirit of nitre in sweetened 
water, and repeated according to circumstances, will be of 
service. 



CHAPTER XIV. 

GONORRHCEAL RHEUMATISM. 

Medical science has not as yet shed any light upon the 
specific cause of this disease. But the circumstances which 
appear to bring this cause, whatever it may be, into active 
operation in certain individuals, are for the most part within 
our comprehension. The practitioner usually ascertains upon 
inquiry that the patient in whom the affection is developed as 
a complication of urethral discharge, possesses some marked 
peculiarity of temperament, — very probably the lymphatic ; or 
has a hereditary tendency to rheumatism or gout ; or perhaps 
is suffering from dyspepsia or constitutional debility ; or has 
exposed himself to some adverse agency, as cold, and wet, and 
wind. It is frequently associated with orchitis. It occasion- 
ally seizes upon the fleshy parts of the frame, as the shoulders, 
the intercostal muscles, the hips, the thighs, soles of the feet, 
etc. But the most usual, and by far the most important and 
inveterate, form which the complaint assumes, is that which is 
known under the designation of articular or gonorrhoeal rheu- 
matism, or gonorrhoeal inflammation of the synovial membranes. 
Some men are sure to have articular rheumatism whenever 
they contract blennorrhagia ; and it is by no means uncommon 
for patients who have the synovial inflammation to have, sim- 
ultaneously, some form of ophthalmia. Sir Astley Cooper 
mentions that the first case of gonorrhoeal rheumatism he ever 
met with was in an American gentleman, who had had gonor- 
rhoea twice before he saw him. During both these attacks he 
had double ophthalmia and articular rheumatism in both knees ; 
and the third visitation of blennorrhagia was also remarkable 
for the same complications. 

To the wakeful and discriminating genius of Sir Benjamin 
C. Brodie, the profession is indebted for the first description of 
this complaint, a few cases of which are to be found in his 

(156) 



GONORRIICEAL RHEUMATISM. 157 

" Diseases of the Joints." This singular affection, like that 
which diffuses itself among the muscular and fibrous tissues as 
a complication of blennorrhagic discharge, may come on at 
any period ; although it seldom shows itself until the latter 
has materially declined or entirely ceased. The knee is by 
preference most frequently the seat of the disorder, but other 
superficial articulations are liable to be attacked. The synovial 
sheaths of the extensor tendons on the wrist and instep are 
sometimes involved. In most instances, only one joint is im- 
plicated at a time ; in other cases the disease invades several 
articulations at once. The inflammatory action is suddenly 
lighted up, and without previous warning, is not particularly 
violent in its features, is wont to linger as a subacute affection 
for an indefinite period, to the discomfort of the patient and 
the embarrassment of the physician. In consequence of syno- 
vial effusion, the joint becomes much enlarged ; and if the 
complaint occupy the knee, the fluctuation of the effused fluid 
can easily be detected at an early period. The effusion remains 
for several months after the other symptoms have disappeared. 
In spite of every exertion of the medical attendant for its re- 
moval, the swelling yields with great reluctance ; and often, 
on slight provocations, returns with surprising rapidity, first 
in one knee, then in the other ; and in this way the patient is 
tormented for years. There is ordinarily but little constitu- 
tional disturbance. The integument covering the joint pre- 
serves its natural temperature and color for a considerable 
time, even when there is a great increase in the size of the 
joint. In some rare instances, the accompanying symptoms 
become general and severe. The pulse is full and quick, the 
stomach and other organs of digestion sympathize, and the 
patient falls into a decline. In other individuals, the inflam- 
mation will proceed through its whole course without being 
attended with any symptoms of effusion. In still other cases, 
endocarditis and effusion into the pericardium have taken 
place ; also compression of the spinal cord and of the brain, 
and which appeared to follow the articular affection. The 
usual symptoms of acute rheumatism are seldom developed, 
and when they are manifested, they are moderate in degree ; 
the constitutional disturbance being quite trifling, when con- 
trasted with the severity of the local arthritic affection. Mr. 
14 



158 GONORRHCEA AND SYPHILIS. 

Johnson thus expresses himself in regard to this disease : " I 
am disposed to imagine that there is not quite so much of the 
peculiar and specific about gonorrhceal rheumatism as is com- 
monly believed. It has all the features of what is properly 
called 'rheumatic gout,' and I have seen no case which, the 
gonorrhceal discharge away, could readily be distinguished from 
it. Rheumatic gout is an inflammatory affection of the syno- 
vial membranes, erratic in its habit, rather giving rise to rapid 
effusion than to violent inflammatory action, chiefly affecting 
the articulation of the knee, sudden in attack, tedious in course, 
and treacherous in recurrence. What are these but the charac- 
ters of gonorrhceal synovitis ? " 

Suppuration has taken place where the patient has received 
the most judicious treatment, and has in all respects been 
under the best hygienic influences. Suppuration, however, or 
the formation of abscesses within or around the joint, is a rare 
accident. 

Diagnosis. — The almost total absence of pain, the normal 
aspect and warmth of the skin, and the apyrectic condition of 
the system usually attendant on the complaint in its early 
stages, are to be set down as the most reliable characteristic 
marks which it exhibits, and may serve, when taken in connec- 
tion with the history of the patient, as sufficient grounds for 
separating it from ordinary rheumatism, and from those neu- 
ralgic and nocturnal pains which a person not unfrequently 
experiences in the latter stages of constitutional syphilis. In- 
stances, however, arise, in which a differential diagnosis is diffi- 
cult and even impossible ; but fortunately, as regards the treat- 
ment, this is a circumstance ,of small moment. 

Treatment. — It was once considered proper surgical prac- 
tice in cases of gonorrhceal rheumatism, to court a return of 
the urethral discharge, if that discharge had disappeared or 
had materially diminished on the accession of the synovial 
disease. And in order to reestablish the blennorrhagia, it was 
the custom of some practitioners to irritate the canal by hav- 
ing the sick man wear a bougie for a portion of each day, or 
to inoculate the mucous membrane with the infectious mat- 
ter borrowed from another person. The same course was 



GONOKRHGBAL RHEUMATISM. 159 

advised in ophthalmia arising in connection with urethritis. 
The idea of metastasis suggested these plans. Whether the 
theory be sound or not, the inoculation of the urethra with 
gonorrhoea! virus or even the introduction of the bougie for 
the purpose of exciting and irritating the urethra, anew, is now 
reprobated by all judicious members of the profession. Were 
it within our power to obtain the history of a large number 
of instances of rheumatism directly related to gonorrhoea, it 
would probably be found that the influence of the former 
upon the latter, in ordinary cases, is not of a very decided 
character ; and that the decrease or total cessation of the dis- 
charge, when it does take place, is merely an incidental cir- 
cumstance. 

Although the complaint is apt to be one of great obstinacy, 
yet it is in the power of the physician to do much to relieve 
the severity of the symptoms, and sometimes to cut short 
their duration. In the commencement of pain and swelling 
of the joint, the patient should be directed to take his bed. 
The treatment must of course be both local and constitutional. 
Leeches should be applied to the affected joint. The quantity 
of blood to be extracted must be in proportion to the violence 
of the inflammatory action and the ability of the patient to 
sustain depletion. The employment of general blood-letting 
will rarely be called for. The abstraction of a small quantity 
of blood by means of leeches, repeated at short intervals, will 
be the safer practice. In a majority of cases, the patients we 
have to deal with, although young or in the meridian of life, are 
far from being robust. Not a few of them are of strumous 
diathesis, or have impaired their constitutions by imprudence, 
and are unable to endure loss of blood to any great extent. 
Warm fomentations, evaporating lotions, and vapor baths to 
the joints, should always be used several times in the day ; also 
large poultices, containing laudanum, belladonna, or the Amer- 
ican hellebore, should be applied at night. In many instances 
of articular rheumatism, I have known veratrine applications 
bring alleviation of pain in a very short time. I am disposed 
to place a higher therapeutic value on poultices containing a 
large portion of the pulverized veratrum viride than on either 
of the other agents mentioned in this connection. The poul- 
tice should be large enough to cover the whole joint, and be 



160 GONORRHOEA AND SYPHILIS. 

put on as warm as can be borne. If there be much arterial 
excitement, the saturated alcoholic tincture of the veratrum 
may be administered internally. This preparation has been 
used quite extensively by physicians in various parts of the 
country, and its efficacy as a diaphoretic and arterial sedative 
abundantly proved. Professor Carnochan, of New York city, 
has prescribed it successfully in many cases at the Emigrants' 
Hospital. In one instance of articular rheumatism, by the 
exhibition of the saturated tincture in doses of from five to 
eight drops every three hours, a pulse of one hundred and 
twenty was reduced to thirty in fifteen hours. I have recently 
attended a lady who had a pretty severe attack of articular 
rheumatism, which migrated from joint to joint during a period 
of several days. The veratrum was given in tincture, in doses 
of four to eight drops every six hours, according to the urgency 
of the symptoms. In this instance, the remedy appeared to act 
promptly in allaying pain, controlling arterial action, and pro- 
curing sleep. No opium in any form was used. The Drs. 
Cutter, father and son, two highly intelligent and reliable phy- 
sicians of Woburn, near Boston, give ten drops of the saturated 
tincture of veratrum every two or three hours in severe cases.* 

When the disease has existed for some time, blisters are 
among the most efficient local means that can be employed. 
Or, if the physician prefer, the surface can be kept thoroughly 
irritated by frequently painting it with the compound tincture 
of iodine. This will be found a useful substitute for blisters, 
where the latter disturb the urinary apparatus. Compression, 
by means of imbricated bands of adhesive plaster and a narrow 
roller, is another method by which the fluid remaining in the 
articulation may be gradually absorbed. The electro-magnetic 
battery is likewise worthy of a trial when the complaint has 
assumed a chronic form ; also, frictions, with mercurial oint- 
ment, — care being taken to avoid salivation. Long-continued 
rubbing with the bare hand, or with a hair mitten, should like- 
wise be practised many times in the day. 

The wine of colchicum, tincture of sanguinaria canadensis, 

* Since the above was written, an important communication prepared by a 
committee of the Middlesex East District Medical Society, Massachusetts, rela- 
tive to the veratrum viride as a safe and valuable arterial sedative, has ap- 
peared in the American Journal of Medical Sciences, for October, 1858. 



GONORRHEAL RHEUMATISM. 161 

the ammoniated tincture of gum guaiacum, the iodide of potas- 
sium, the nitrate of potash, calomel and opium, have all been 
tried, sometimes with satisfactory results, sometimes with the 
very reverse. Where the febrile action is considerable, and the 
patient of a plethoric habit, brisk cathartics are demanded, and 
ought to be repeated every four or five days. Their employ- 
ment may be persevered in for a long time. But in ordinary 
cases, and where the affection has become chronic, and the 
patient is in rather poor general health, cathartics will not be 
indicated. They will do injury. Mild aperients, tonics, altera- 
tives, diaphoretics, and a generous diet will be suited to the 
condition and wants of the individual. 

A residence in a warm climate, with ordinary attention to all 
the rational principles of health, will sometimes result in the 
recovery of the patient, after the physician has exhausted the 
entire treasury of all remedial agents that have ever been tried 
in this disease. 

14* 



CHAPTER XV. 

VEGETATIONS. 

These morbid excrescences were once, but are not now, re- 
garded as the product of the syphilitic poison. They are some- 
times the result of irritation from the deposit of gonorrheal 
matter ; and sometimes they are generated by the combined 
agency of moisture, heat, and filth, especially in uncleanly 
females, who may or may not have some vaginal discharge at 
the same time. They differ in appearance, and sundry terms 
have been employed to designate them, according to the aspect 
they present to the eye or the fancy of the physician or sur- 
geon ; as, warts, vegetations, tubercle, cauliflower, raspberry 
excrescences ; and, when seated between the nates or on the 
inner surface of the prepuce, where they are subjected to con- 
stant pressure, they have been compared to the crest of the 
cock. The situations in which they are chiefly found are the 
meatus urinarius, the glans, the mucous membrane of a narrow 
prepuce, and at the junction of the two preputial surfaces ; 
when they select the latter site and are allowed to remain, they 
fill up the orifice so as to impede the escape of urine, and other- 
wise interfere with the functions of the penis. In the female, 
they come upon the vaginal surface, vulva, nymphae, orifice of 
the urethra, and upon the inner aspect of the labia. They 
usually begin to appear in the lower part of the vagina, near its 
orifice, and extend upwards along the junction of the mucous 
membrane and skin towards the superior commissure. They 
grow with great rapidity. Even if excised with the knife or 
scissors, they immediately return, provided the blennorrhagia 
continues ; and, if undisturbed, they soon become large and 
vascular, occasioning more or less haemorrhage and severe pain 
when cut off. They are generally soft and spongy when situated 
in these parts, and constitute one of the greatest inconveniences 
that attend gonorrhoea in the female. In some instances, large 

(162) 



VEGETATIONS. 163 

warty excrescences spring from the walls of the vagina at a 
little distance from its orifice, and their presence will keep up 
a discharge for a long time after the blennorrhagia, in which 
they originated, has ceased. The patient, perhaps, makes no 
complaint ; but if she engages in any active exercise, the dis- 
charge will probably return, and be as abundant as ever, and 
the ordinary treatment for arresting it will be employed with 
little or no relief. Under these circumstances, if the speculum 
be used, the locality of these verrucas can be ascertained, and 
they can be removed with the ecraseur, or be destroyed by the 
application of the acid nitrate of mercury. 

In both sexes, vegetations collect around the verge of the 
anus, on the perineal integument, and within the cleft of the 
nates, where the natural moisture and other irritating matters 
are retained. In the recent state, and while lubricated with 
the substance exuded from the mucous surface, they are com- 
paratively soft and white ; if they remain for a considerable 
time, and come in contact with the air, they dry up and become 
quite hard and of a dark color. Sometimes they are broad, 
thick, and flattened ; or they may have a small pedicle or 
stem, by which they are attached to the corium from which 
they germinate, and present a form not unlike a grain of wheat 
or rice. Their anatomical structure consists of a thick, firm 
investment of epithelial laminae and newly-formed cellular 
tissue, which is usually well supplied with blood-vessels and 
nervous loops, and hence the pain and bleeding when the 
growths are removed with the scissors. The epithelium is not 
perforated, but is pushed up without being broken as the vege- 
tation grows. I have seen them in male and female subjects, 
who were and always had been otherwise exempt from disease 
in the parts occupied by these morbid growths, but who had 
no practical notions of personal cleanliness. It is by no means 
difficult to believe that such individuals are just the ones to 
furnish the elements for the formation of these adventitious 
appendages. The wonder is that they do not occur more fre- 
quently. A few months since, an Irish woman called upon me 
to be cured, she said, of a wart as big and as black as " a cock- 
roach," and which had troubled her for about one year. The 
abnormal mass was situated on the pouch at the fourchctte. 
Several small papilliform warts were seen pullulating in the 



164 GONORRHOEA AND SYPHILIS. 

immediate neighborhood of the larger one. They had all been 
destroyed several times, and all quickly returned. The patient 
stated that when they began to trouble her, " they were white 
as any snow." She was sufficiently filthy to suggest the idea 
that these extraneous bodies were the legitimate offspring of the 
soil that nourished them. In this case Goulard's extract of lead 
relieved, but did not cure, the difficulty. 

I am aware that Yidal considers these vegetations as syphi- 
litic in their origin ; and he disbelieves that any other cause can 
give rise to them. This theory is repudiated by nearly all 
syphilographers. It is highly probable, to say the least, that 
they may and do exist without any constitutional taint of a 
specific character. They are incapable of generating any vene- 
real affection ; are seen in their worst forms in the female, and, 
like warts on the hands of children, spring from causes which it 
is not easy to explain. Mr. Acton says : " In females, warts 
depend upon gonorrhoea or irritating discharges ; the secretion 
of chancres often produces them, not, I believe, in virtue of any 
specific action, but from its irritating qualities ; and modern 
authors have ceased to consider them a secondary symptom. It 
is of great importance in medical jurisprudence that these points 
should be properly appreciated." 

Vegetations of a non-specific nature are now and then com- 
plicated with true condylomata, which proceed from a venereal 
cause, and which belong to the circle of secondary symptoms. 
When these condylomatous excrescences exist, other syphilitic 
phenomena will be present also ; or the history of the case will 
show that they have existed at some former period ; and the 
physician will seldom have any difficulty in assuming the right 
position as regards the diagnosis. Some authorities make this 
distinction, — that simple warts are always pedunculated, while 
those that are really syphilitic are always sessile and seated on 
a broad base ; and the granular patch is of a dirty red or 
whitish hue, rather flat than prominent ; secretes a watery, 
yellowish discharge, and having a most disgusting odor. But 
nothing short of a truthful history of the case can furnish a 
perfectly reliable basis, on which to establish a correct diagnosis. 
Mere appearances may deceive the most practised eye. This 
they always have done and always will do. 



VEGETATIONS. 165 

Treatment. — If the warts are in men, and situated on the 
inner surface of the prepuce, their removal is best accomplished 
by circumcision. If located on the glaus, or on the reflected 
portion of the preputial mucous membrane, they can be snipped 
off with a pair of flat curved scissors, and afterwards the radical 
portion be touched with some sharp escharotic, as acid nitrate of 
mercury or the concentrated nitric acid. If very numerous, it 
will hardly be prudent to attempt the destruction of the whole 
by a single operation either with the knife or caustic, but let 
the work be more gradual. Excision is a painful procedure to 
the patient, and will rarely succeed alone in annihilating these 
disgusting formations. 

As a constant application, the liquor plumbi, somewhat 
diluted, is one of the best. It may be used on dossils of soft 
English lint. When the warts are not situated on the prepuce, 
they can generally be removed and be prevented from returning, 
without recourse to the knife or scissors. In addition to the 
astringents and escharotics mentioned above, the bichloride of 
mercury will sometimes act in an efficient manner. It is to be 
used in the proportion of two grains to the ounce of water, as 
directed for Goulard's extract. The chloride of zinc solution is 
preferred by Mr. Emerson, surgeon in the Westmoreland Lock 
Hospital. In a communication to Dr. Egan he says: " I would 
wish to impress upon you the high value I attach to Sir William 
Burnett's solution of chloride of zinc, in all cases of vegetations 
and unhealthy growths, the result of inattention to cleanliness, 
and the accumulation of irritating vaginal secretions. Indeed, 
such is my opinion of its utility in these cases, that I believe it 
cannot be dispensed with. I consider the solution the most 
effectual, and, in some instances, the only, application (the knife 
excepted) that can be relied upon with certainty for the cure of 
the disease." The zinc solution may be applied occasionally 
without being diluted ; but for constant use the strength should 
be from two to four drachms to eight ounces of water. When 
the warts are clustered about the anus or the perinseum, a 
powder consisting of equal parts of savin and burnt alum, 
makes an excellent application. These new formations, when 
they occur on the external integument, are limited to distinct 
portions of the papillary stratum of the true corium, or of 
the sebaceous follicles. They are often known under the name 



166 GONORRHCEA AND SYPHILIS. 

of acuminated condylomata, and have very properly been 
termed papillomata. The projections which constitute the 
papilloma sometimes terminate in acute points ; sometimes in 
truncated, clavate extremities ; and are in some instances sup- 
ported on a slender neck, or on a broader- basis ; occasionally 
quite a number, grouped together, rise on a common stock, or, 
crowded more closely, constitute a group, separated by lateral 
furrows, which give them a cauliflower appearance.* 

Case. — A young printer, unmarried, came to me a few 
months ago with numerous pedunculated warts situated around 
the anus and along the perineal integument. Five or six years 
since, he had a chancre on the glans penis. It was readily 
cured, and his general health never suffered in consequence of 
this primary accident. The warts began to appear seven or 
eight months before I was consulted. The largest were the 
third of an inch, the smallest the tenth of an inch in length. 
The patient was directed to wash the parts thoroughly in warm 
water and soap, and to apply the powder of savin and alum 
morning and night. In three weeks the excrescences were com- 
pletely destroyed and did not reappear. No other treatment 
was used. This is a fair specimen of the effects usually derived 
from this powder. In many instances the locality of the vegeta- 
tions renders its application impracticable ; but where it can be 
used conveniently, its agency in destroying the abnormal 
growths is rapid, without being very painful. Escharotics all 
act much in the same way ; and in ordinary cases there is no 
great choice in them. In some instances, however, there is a 
preference arising from the character, locality, and extent of 
surface occupied by the vegetations. If they are flattened and 
exist in large groups, whether on the cuticular or mucous 
surface, and excision be not admissible, the acid nitrate of 
mercury will act as favorably as any topical remedy. A con- 
venient method is, to moisten the end of a glass rod or a camel's 
hair pencil with the fluid. A quantity sufficient to turn the 
surface of the vegetations white, is to be used, and no more. 
The process is somewhat painful, but perfectly destructive to 

* A minute description of these papillomata may be found in Wedl's Patho- 
logical Histology. 



VEGETATIONS. Iff 

the morbid growths. If the cluster be very large, it will not be 
best to treat the whole at one time ; but the surgeon should 
wait four or five days, and then attack another portion. After 
the application of the acid, lint, soaked in warm poppy- 
water, ought to be placed in contact with the part, and the 
patient should remain quiet for some hours. 

A solution of chromic acid has lately come into use in the 
treatment of warts of the genital organs and other parts, 
whether resulting from syphilis, gonorrhoea, or other irritating 
discharges. The strength of the solution should be in the pro- 
portion of one hundred grains of crystallized chromic acid to a 
fluid ounce of distilled water. It is best applied by means of a 
pointed glass rod as directed for the use of acid nitrate of mer- 
cury. Only so much should be employed as will saturate the 
diseased growth. Care must be taken to avoid the adjacent 
healthy tissue ; for although the solution is not sufficiently 
powerful to destroy or even vesicate the mucous surface, it may 
provoke an unnecessary inflammatory action. Any superfluous 
acid may be removed by a piece of wet lint. The acid gives 
but a trifling amount of pain. Warts situated on the vulva, 
labia, perinaeum, anus, prepuce, glans, etc., may be treated 
with it, with safety and success. One application is generally 
sufficient. A purulent discharge ensues, and under its influence 
the morbid excrescences speedily waste away. The proper 
dressing to the parts after the application of the acid, is dry lint, 
or lint wet with diluted lead-water. If the warts are numerous, 
the same rule should be observed in attempting their removal as 
was suggested in the employment of the acid nitrate of mercury, 
that is, to attack a part of them at a time. 

Whatever local measures are put in force for removing the 
disease, whether in the male or female, the patient must not 
forget that after the cure has been completed, a recurrence is to 
be apprehended, unless the most scrupulous attention to clean- 
liness be observed. 



CHAPTER XVI 

BLENNORRHAGIA IN THE FEMALE. 

£he Speculum. — Of late years, the speculum has been 
resorted to as an important means of diagnosis, in morbid 
affections that invade the vagina and uterus ; and the clinical 
demonstrations which its use is capable of affording in a variety 
of cases cannot be too highly appreciated. More, than two 
thousand years ago, this instrument was employed as a means 
of ocular inspection ; but through agencies, and for reasons not 
now apparent, it drifted out of the current of medical and sur- 
gical practice, and for many long centuries remained in a state 
of oblivion, until about sixty years ago it was again brought into 
limited use by M. Recamier, of France ; and still more recently 
through the active genius of Ricord, it has become one of the 
most popular and efficient means for obtaining an exact knowl- 
edge of uterine lesions. And considered in a therapeutic point 
of view, its merits, in certain cases, can scarcely be exaggerated. 
Among what we term in medical parlance female diseases, 
and which we are called upon to investigate and treat, blen- 
norrhagia, proceeding from some portion of the generative 
system of the female, is one of the most common ; and. by 
the use of the speculum, the practitioner can arrive at a 
degree of certainty in regard to the pathological condition of 
the parts which it is impossible to acquire through the blind 
medium of digital examinations. The latter, under the most 
favorable circumstances, give but an imperfect knowledge of 
any morbid changes that may take place. The sense of touch 
needs the assistance of the eye. The advantages of instrumental 
explorations do not consist merely in bringing to view any 
particular lesion that cannot otherwise be detected. They 
relate directly and chiefly to therapeutic measures. Certain 
modes of treatment, certain topical and constitutional remedies, 
possessing specific qualities, adapted to particular functional or 
structural derangements, and to no others, are thus suggested 

(168) 



BLENNORRHAGIA IN THE FEMALE. 169 

to the judgment by what the eye has seen. In the same man- 
ner, an examination within the buccal cavity, by means of a 
spatula, leads to definite conclusions in regard to any morbid 
condition of the mouth and throat. Cases not subjected to such 
inspection must necessarily be conducted, in some degree at 
least, according to the doctrine of chances. No sagacity or 
experience is sufficient to guide the physician in the best way, 
independently of the speculum. Neither the exact locality nor 
the precise nature of the abnormal condition can be recognized 
in a satisfactory manner ; and the line of treatment must be 
laid out and pursued under no little disadvantage. Here the 
blind lead the blind ;. and although neither may literally realize 
the catastrophe spoken of in connection with this implied igno- 
rance, it is certain that both must suffer from it in more ways 
than one. 

There are circumstances and conditions in which instru- 
mental examinations cannot be made. To employ the speculum 
in severe inflammatory gonorrhoea, accompanied with tumefac- 
tion of the labia, would be an abuse of the instrument and of 
the patient. The surgeon must suspend its use until the acute 
symptoms have been subdued. After this, the speculum should 
be employed for the purpose of ascertaining whether any ero- 
sions, vegetations, chancres, or ulcerations coexist with the blen- 
norrhagic discharge. It not only gives clearness and precision in 
diagnosis, but it can be employed as a surgical guide to render 
more facile the application of caustics or escharotics, in the use 
of which caution and exactness of manipulation are necessary. 
The speculum may, without impropriety, be regarded as suited 
to a numerous class of females who require medical and sur- 
gical treatment, and who are always anxious to be cured in the 
shortest time possible. 

With the instrumentalities now at his command, the intelli- 
gent practitioner asks only for a few days to accomplish a cure 
of maladies, which, while the speculum was ignored, were sub- 
jected to a tedious and oftentimes random treatment of many 
weeks or months. Several kinds of speculum are in vogue. 
The bivalve is generally preferred. The common, conical form 
is easier to manage, throws a sufficient quantity of light upon 
the part that is brought into view, and usually answers every 
purpose. 

15 



170 GONORRHOEA AND SYPHILIS. 

Diagnosis of Blennorrhagia in the Female. — The inves 
ligation of this subject is often beset with difficulty and embar- 
rassment. The impossibility of determining in all cases be- 
tween a gonorrhoea resulting from infection and one that 
has no such origin, is acknowledged by all practitioners. Such 
instances are occasionally met with in the male subject, but 
in the female they are very frequent. Especially do they occur 
in women who have long been troubled with some chronic 
secretion of obscure character, assuming different appearances 
at different epochs ; being at one period mucous, at another, 
muco-purulent, or muco-sanguinolent ; and so on, through still 
other transformations ; sometimes attended with but little incon- 
venience, at other times fretting and irritating the surfaces over 
which it flows. To these chronic cases the difficulty of discrim- 
ination is chiefly confined. 

Neither chemical nor pathological investigations have as yet 
furnished any thing like the requisite data by which we might 
decide in any given case as to the contagious or non-contagious 
properties of these abnormal exudations. Were we at liberty to 
make experiments in the inoculation of these vitiated secretions, 
we should still fail to have any absolute criterion, or to acquire 
any incontestible evidence in the premises, so far as relates to 
the true gonorrhoeal element derived by contagion from another. 
For it must be admitted that the vaginal secretions of some 
females who are perfectly chaste and entirely free from all 
gonorrhoeal taint, may give rise to urethral inflammation and 
blennorrhagia in some men. Leucorrhoea has the credit of 
doing this. The same power is claimed in behalf of normal 
menstrual fluid. There are not a few able writers who have 
implicit faith in the ability of both these secretions to .provoke a 
blennorrhagic urethral discharge. Candor, indeed, compels me 
to go farther, and to admit that an acrid condition of the ordi- 
nary mucous moisture, — the epithelial exudation from the 
uterus or the vagina, — may generate a gonorrhoea in the male. 
But this male, in my opinion, must be endowed with some 
peculiar idiosyncrasy, some remarkable aptitude, which predis- 
poses him to receive the infection. Thus, extraordinary con- 
ditions appertaining to both parties at the same time, may 
occasion non-specific symptoms in a man, that -cannot be dis- 
tinguished in their severity, duration, or complications, from 



BLENNORRHAGIA IN THE FEMALE. 171 

those phenomena attributable to contagion derived from a 
woman, who has, and who gives, a veritable blennorrhagia at 
the moment of sexual congress. Such instances are, however, 
exceedingly rare. They will do to be mentioned as mere excep- 
tions to the general rule, and this ail they are worth. All these 
contingencies, these exceptions, and these extraordinary circum- 
stances, demonstrate the paramount importance of having a 
full and truthful history of the case presented to the medical 
attendant for his careful consideration. If, short of such a his- 
tory, he attempts to form an opinion, he will find himself some- 
times, and when he least expects it, leaning upon a broken staff. 
Practitioners of no little tact and experience have been placed 
in such a predicament. 

Professor Bennett, speaking of inflammation of the vagina and 
vulva, says that he considers the secretion of a great quantity 
of pure pus from the vaginal mucous membrane as all but 
pathognomonic of blennorrhagic inflammation. " An important 
fact in connection with vaginitis," says he, " to which I have 
already drawn attention, is, that it seldom exists for any great 
length of time as a primary disease, whether purely inflammatory 
or blennorrhagic, without extending to the mucous membrane of 
the cervix. Hence it is, that blennorrhagia, a disease in which 
the inflammation no doubt commences in the vagina and vulva, 
the cervix is nearly always, after a short time, found to be con- 
gested and inflamed, and eventually, if the disease is not cured, 
ulcerated. Like those who have preceded me, I am unable to 
point out any absolute means of distinguishing between simple 
inflammation of the vagina and blennorrhagic inflammation, 
although I am convinced that a difference does exist. This, 
indeed, is proved by the fact that simple inflammation of the 
vulva and vagina does not, as a general rule, communicate 
blennorrhagia to the male, although I admit fully that an occa- 
sional exception may take place. My dispensary patients are 
nearly all married or single women, amongst whom I seldom 
meet with syphilitic disease, and in the higher ranks of life it is 
still more rare, not existing in one uterine case out of fifty for 
which I am consulted. Nearly all these females in both classes 
of the community are suffering from vaginitis, as described 
above, in a more or less acute form, when they apply for advice ; 
and yet although they have generally lived with their husbands 



172 GONORRHOEA AND SYPHILIS. 

up to the time they consult me, the wife has nearly always a 
tale of sorrow to record ; her husband is wild, dissipated, keeps 
bad company, sleeps out at night, and generally speaking, has 
confessed to her that he has exposed himself to contagion. 
The only anatomical differences, however, which I have ob- 
served in blennorrhagic inflammation, are the very great quan- 
tity of pus secreted, the extreme redness, congestion, and 
swelling of the mucous membrane, the occasional extension of 
the inflammation to the urethra, and its extreme intractability 
to treatment." * 

Young female children are sometimes troubled with a dis- 
eased condition of the genital organs, presenting symptoms 
very much like those arising in the female of adult age. The 
trouble usually commences in the prczputium clUoridis, which, 
from some accidental cause, becomes inflamed ; and the affec- 
tion afterwards extends gradually to the labia, nymphae, and 
perhaps to the vagina. In some instances, small ulcerations 
form here and there upon the mucous membrane, which yields 
very little purulent discharge. In other cases, erosions take 
place, or there is an aphthous condition of the parts, attended 
with a serous exudation more or less copious, and irritating to 
the surface with which it comes in contact. In still other in- 
stances, but of very infrequent occurrence, a leucorrhceal dis- 
charge is noticed, apparently from the vagina, while the other 
associate organs remain healthy, and the child is otherwise 
well. In none of these cases do the symptoms assume a spe- 
cific character. They may awaken alarm in the mind of the 
mother, and sometimes suspicion may be excited that foul play 
has been practised upon the child by a person having a gon- 
orrhoeal or venereal affection, when such is not the fact. A 
few months since, I was requested to examine a little girl 
about five years old. She had muco-purulent discharge from 
the vagina, — the external organs being free from disease. 
The child was sent to Rainsford Island Hospital. The symp- 
toms were of a mild type, but several weeks passed before a 
cure was accomplished. By the parents the trouble was 
thought to have originated with a servant girl, of bad repute, 
who slept with the patient. A similar instance came under 
my observation several years ago, in a child two years of age, 

* Bennett on the Uterus, p. 179. 



BLENN0RRHAG1A IN THE FEMALE. 173 

and requiring treatment for more than two months. In this 
case, there did not seem to be ground of suspicion against 
any individual, nor was the cause of the difficulty apparent. 
Dr. R. H. Salter informs me that he has recently had under 
his charge two female children, one aged eight years, and the 
other eleven, affected with urethral and vaginal blennorrhagia. 
The mother was under his treatment for the same disease at 
the same time.- The only way of accounting for the occur- 
rence of the complaint in the children was, that the mother 
used the same napkins for wiping the children, after bathing, 
which she had just before employed on her own person. A 
few years since, two similar instances were reported by Dr. 
Burke Ryan before the London Medical Society. Two children, 
sisters, aged respectively one and four years, were found labor- 
ing under a profuse vaginal discharge. There was high fever ; 
the parts were much swollen, with great pain in micturition. 
The explanation as to the mode of communication of the 
disease to these children was this : It was ascertained that 
a young woman in the house had profuse gonorrheal dis- 
charge ; that she washed herself in the same vessel used for 
washing the children ; that she used about her private parts the 
same sponge which was employed for them, and sat upon the 
same vessel which they did.* 

As the foregoing cases are well authenticated, they are im- 
portant in reference to matters of medical jurisprudence. Sim- 
ilar accidents might happen to females of adult age. 

If a young female with mucous or purulent discharge 
showing itself at the external genital organs, is presented for 
examination and treatment, it will usually be an easy matter 
to determine whether any attempt at intromission of the virile 
organ has been made by an adult male. Any such effort will 
be very likely to be followed immediately by inflammation and 
swelling of the soft and delicate structures of the labia and 
nymphas ; and laceration, or other injury, about the entrance 
of the vagina, will be detected. If no marks of violence can 
be discovered, the morbid condition of the parts must be attrib- 
uted to some other cause — as the accumulation of filth, irri- 
tation from the clothing, or some intestinal derangement. 

* London Medical Gazette, April, 1851, p. 744. 

15* 



174 GONORRHOEA AND SYPHILIS. 

Situation. — Blennorrhagic inflammation, attended with a 
specific discharge, eminently contagious, attacks the mucous 
membrane of the vulva, the vagina, urethra, and uterus. In 
very mild cases, the abnormal action is confined to this mem- 
brane ; but, in most -instances, it penetrates into the subjacent 
tissues. It is usually limited to some portions of the genito- 
urinary apparatus, although in certain cases which have been 
neglected, or which, from some special circumstances, resist 
the ordinary therapeutic measures, the malady propagates itself 
throughout all the organs. Among the ulterior accidents result- 
ing from blennorrhagia, may be mentioned cystitis, nephritis, 
inflammation and obliteration of the Fallopian tubes, ovaritis, 
sterility, peritonitis, inflammation and suppuration of the in- 
guinal lymphatic glands and of the labia majora, chronic en- 
largement of the nymphse, etc. 

Varieties. — As the morbid process takes place in certain 
localities, while other portions of the genital organs are not 
implicated, the disease may very properly be considered under 
several varieties, according to the situation it occupies. The 
vulva and vagina are most frequently the seat of catarrhal in- 
flammation. 

Symptoms. — Among the earliest symptoms which announce 
the approach or actual existence of the disorder, are, a pe- 
culiar tickling and itching sensation in the parts, amounting, 
in some women, to a sort of temporary nymphomania. The 
labia majora are swollen, and upon separating them, the whole 
mucous surface thus brought to view is found to have under- 
gone a material change. An erythematous redness, with a 
turgid condition of what is called the vulvar circle, is mani- 
fest. Serous infiltration takes place into the cellular tissue of 
the nymphae, greatly distending these bodies, which protrude 
through the external labia, and become cedematous, constricted 
and extremely sensitive. The patient is scarcely able to walk 
about, or even to sit down, on account of the local suffering 
she experiences. The bladder is disturbed by sympathetic 
irritation ; micturition is frequent and painful, although no 
urethritis exists. The tumefaction of the neighboring parts 
interferes with the free exit of the urine, the diffusion of which, 



BLENNORRHAGIA IN THE FEMALE. 175 

over the inflamed surface, causes no inconsiderable smarting 
and scalding. The inflammation soon reaches the vagina and 
spreads in circumscribed patches, or perhaps extends through- 
out the whole of its mucous membrane. Its numerous papillae 
and follicles become hypertrophied ; its walls contract and 
present a granular aspect ; and if the inflammation reach a 
high point, abrasions of the epithelium are here and there 
seen in the form of lenticular spots, which give to the mucous 
surface a salmon-like appearance ; and if the force of the dis- 
eased action be not checked, ulcerations are formed. These 
bear considerable resemblance to diphtheritic venereal sores ; 
but they are more superficial than the latter, and in many 
instances, when examined with the speculum, they can be seen 
in their different stages of development. They yield to treat- 
ment more readily than any syphilitic affection which has an 
apparent affinity or likeness to them. 

Simultaneously with the preceding manifestations, a copious 
mucous discharge appears. This very soon becomes puriform, 
and is poured out in great profusion. Sometimes a vesicular 
eruption, induced by the irritating qualities of the blennor- 
rhagic secretion, breaks out upon the perineal integument, 
the inner aspect of the thighs, and other neighboring parts. 
When the eruption is impetiginous, it is apt to remain for a 
long time, and may be, and often is, mistaken for a true ven- 
ereal eruption. Its persistent character is generally conse- 
quent upon uncleanliness. The blennorrhagia, either from neg- 
lect or mismanagement, very frequently degenerates into a 
chronic vaginitis. The discharge lessens in quantity, con- 
tinues to be more or less purulent, and usually retains its 
specific virus to the last. The patient is exempt, perhaps, 
from nearly all the concomitant symptoms that characterized 
the initial stage of the complaint, — from which circumstance 
she arrives at the erroneous conclusion that simple leucorrhoea 
is her only trouble ; but if sexual intercourse be indulged in, 
the other party is pretty certain to find that he has sought pleas- 
ure at a poisonous fountain. 

Treatment. — Although, under ordinary circumstances, gon- 
orrhea in the female does not affect so severe a type as in the 
male, it is, nevertheless, in all its essential features, nearly as 



176 GONORRHOEA AND SYPHILIS. 

difficult to manage in the one as in the other. During the 
menstrual period, there is an increased afflux of blood to the 
sexual apparatus of the female, and also at this time an exacer- 
bation of the blennorrhagic affection. To these disadvantages 
another remains to be added : while the menses are present, no 
local treatment can be pursued ; whereas, this constitutes an 
important means of cure, especially while the difficulty is con- 
fined to the vulva and vagina. 

In the acute form of vaginal blennorrhagia, antiphlogistic 
treatment is always appropriate. The patient must be confined 
as much as possible to the recumbent posture. Saline aperients 
should be taken in quantities sufficient to act on the bowek 
freely. Three or four drachms of sulphate of magnesia, in the 
early part of the day, will generally accomplish all that is 
required in this particular. Warm diluent drinks, such as 
toast-water, rice-water, or a weak decoction of eupatorium per- 
foliatum, with a liberal quantity of the liquid acetate of ammo- 
nia, may be taken for the purpose of exciting and sustaining a 
free diaphoretic action. Weak orangeade or lemonade will 
also be found beneficial. Advantage will always be gained 
from the employment of warm baths, resorted to in the evening. 
They tend to equalize capillary circulation, and thus relieve the 
local engorgement. A low, unstimulating diet is to be observed. 
In acute cases, and while the mischief is confined to the vulva 
and vagina, these constitutional measures are about all, of this 
description, that will be necessary. It is a local inflammation 
that we have to deal with, more or less intense, but in which 
there is rarely any great constitutional participation. In most 
instances, the condition of the tongue, pulse, and skin, demon- 
strates this. 

Balsam of copaiba, which is so valuable a remedy in urethri- 
tis, is wholly impotent in vaginal gonorrhoea. 

The following mixture will, in the generality of cases, be 
found as suitable and efficient a remedy as any in arresting the 
last-named variety of blennorrhagia : — 

R. Tincturse Lyttse, 

Tincturse Cubebse, aa, § ij. 

Aquae Camphorse, § iv. 

Morphia? Sulphatis, gr.iv. M. 

Dose. — One drachm three times a day, in a gill of rice-water or toast-water. 



BLENNORRHAGIA IN THE FEMALE. 177 

If no inconvenience arise from this quantity, the patient may 
take four or five drachms in the twenty-four hours. It is sel- 
dom that strangury occurs to a degree that requires artificial 
relief; but if this should be the case, a warm bath or an extra 
fourth grain of morphia, in half an ounce of camphor-water, will 
prove a sufficient antidote. A little inconvenience or scalding 
in micturition, if occasioned by the above' mixture, is evidence 
in favor of its use, although the amount of the medicine should 
be less than at first. If the disagreeable impression here 
referred to should be realized, the patient may cherish a con- 
fident expectation that a cessation of the blennorrhagia will 
speedily follow. 

Local Treatment. — Injections are chiefly to be relied upon, 
as topical remedies, in subduing acute blennorrhagia in the 
female. Although somewhat discordant views prevail in regard 
to the value of this class of medicines in urethritis in the male, 
there is no discrepancy as relates to their free employment in 
vaginitis. Injections of a soothing or emollient nature, rather 
than those which exert a tonic or astringent effect, are to be 
preferred in the early period of vaginal inflammation. Warm 
water constitutes one of the best injections that can be used. 
In order to derive from it all the benefits which it is capable of 
affording, it should be repeated many times in the day. It not 
only keeps the inflamed mucous surface and the other parts 
comparatively exempt from the irritation of the abnormal secre- 
tion, but exerts a decidedly curative influence upon the dis- 
eased tissue itself. A thin mucilage, made of the powdered 
slippery elm bark, constitutes a soothing and quite useful injec- 
tion ; flax-seed tea, and a weak decoction of poppy, are likewise 
beneficial, and may be vised as directed for simple warm water 
injection. Either preparation, here spoken of, will serve a val- 
uable purpose in appeasing the irritable and engorged condition 
of all the parts implicated in the blennorrhagic complaint. In 
order that the injection may irrigate the upper portion of the 
vaginal cavity, and be prevented from escaping prematurely, 
the patient should lie on her back, with the pelvis elevated, at 
the time of using the syringe. What is termed the " pump- 
syringe," with a vaginal tube, is efficient and convenient The 
tube should be inserted to the distance of about three inches. 



178 GONORRHOEA AND SYPHILIS. 

A pint or more of water or mucilage can be thrown up in a few 
moments, without removing the syringe. As the patient's 
recovery is based in no small degree upon the use of injections, 
every practicable facility should be afforded for the best method 
of employing them ; and no expense, necessary for procuring 
the right kind of apparatus, will be lost. If a pump-syringe 
cannot be procured, a metallic instrument, having a long 
curved tube or pipe, and capable of holding six or eight ounces, 
or a vulcanized India-rubber bag, with a long tube made for the 
purpose, will answer.* 

A tampon of soft lint should be placed between the labia, 
and warm fomentations applied during the intervals between 
the injections ; and while the active stage continues, warm 
baths should be used daily. As soon as the severity of the 
local symptoms has materially abated, injections, different from 
those mentioned above, must be substituted. Those containing 
the French chloride of soda will be found useful. Generally it 
will be advisable to commence with one ounce of the chlorine 
solution to one pint of water, and let the patient inject two or 
three ounces repeatedly. It should reach every part of the 
vaginal canal. If, after a trial of six or eight days, the chlorin- 
ated water does not yield satisfactory results, it should be aban- 
doned, and the nitrate of silver be employed in its stead. If 
the condition of the parts will allow the speculum to be inserted, 
the mucous membrane can be examined, and the solid nitrate 
of 'silver applied, either wholly or partially, over its surface, 
according to the seat of the disease. The cases really demand- 
ing this local treatment, however, are few in number, compared 
with those in which its use is not called for. The immediate 
effect is to augment the discharge ; but after a few applications, 
which may be repeated every third or fourth day, it will gener- 
ally arrest it in a short time. If the surgeon decide to try the 
silver, the entire surface of the mucous membrane should be 
thoroughly cleansed with warm water injections previous to its 
employment. While the vagina is thus treated with the silver, 
a solution of alum, to the amount of two scruples to twenty 
ounces of water, may be injected several times during the day. 

* Very good syringes for vaginal use are manufactured by Mr. Thomas 
Lewis, of this city ; also by Mr. Davidson, of Charlestown, Mass. 



BLENNORRHAGIA IN THE FEMALE. 179 

A solution of nitrate of silver is a favorite with many sur- 
geons. In some instances, objections obtain against its use, 
from the fact that it soils the linen. It also requires a glass 
syringe, which, especially in the hands of the patient, is not an 
entirely safe instrument. 

Tincture of iodine is a serviceable remedy in the gonorrhoea 
of females. Like the nitrate of silver, it stains the linen, and 
on that account is sometimes objected to. A single application 
is frequently sufficient to arrest the discharge. The vagina will 
tolerate an injection of higher strength than would be proper 
for the male urethra. In the proportion of § ss. to gviij. of 
water, it may be thrown up three times a day, and it may be 
prescribed in the early period of the complaint, even if there be 
considerable inflammation ; but its efficacy will be more appar- 
ent when there is ulceration of the vaginal mucous membrane, 
or about the cervix uteri. M. Boinet, of France, uses the tinc- 
ture of iodine, with an equal quantity of water, with great suc- 
cess as a local curative in this affection. 

The recent infusion of red bark with nitric acid, furnishes an 
excellent tonic and astringent injection, and is suited to all 
forms and varieties of the complaint, after the more acate 
symptoms have subsided. Let me add that it is equally valua- 
ble in cases of ordinary leucorrhcea. 

It. Infusionis Cinchonae Rubrae B x. 

Acidi Nitrici, gtt. xx. 

M. To be used repeatedly during the day. 

The chlorate of potash is likewise 'worthy of a trial in gonor- 
rheal and vaginal inflammation. It has been prescribed with 
the same well-known success that attends its use in stomatitis. 
The subjoined prescription is appropriate : — 

R. Tannin, Bij. 

Potassae Chloratis, 5j. 

Aquae Fontanae, § xvj. M. 

Injection. 

The patient may use an ordinary female syringeful at a time, 
and repeat the operation ad libitum. Its beneficial effects gen- 
erally declare themselves in a few days. 



180 GONORRHOEA AND SYPHILIS. 

Chronic Vaginitis. — This is a gleety condition of the parts, 
with a thin muco-purulent discharge, which it is often difficult 
to distinguish from common leucorrhoea. It can usually be 
successfully managed with astringent and tonic injections. 
Mention has already been made of one or two of this class of 
remedies. Besides these, there is a long list of others bearing 
a similar character. The liquor plumbi is one of the most 
trustworthy. It should be used repeatedly during the day, in 
the proportion of half an ounce to eight or ten ounces of water. 
A saturated solution of alum is good. It may be employed 
once in the twenty-four hours, and in the interim the surface 
of the vagina ought to be freely bathed with cold-water injec- 
tions. The latter may be regarded as both tonic and astringent 
in their curative action, and may be resorted to with the great- 
est freedom. 

The speculum is to be introduced every few days to ascer- 
tain the precise lesion of the parts, provided the case does not 
progress favorably under ordinary treatment. Through this 
instrument the mucous surface can be touched, from time to 
time, with the nitrate of silver, or with the compound tincture 
of iodine. A small probang is to be moistened with the latter, 
and applied wherever any aphthous patches, erosions, or ulcera- 
tions exist. I prefer the iodine to the silver. The nitric acid 
likewise affords a suitable application, especially if ulcerations 
are detected. It should be tried cautiously every third or 
fourth day. 

Vaginitis is often prolonged' in consequence of the walls of 
the canal coming in contact. To obviate this, let a small roll 
of lint be passed through the speculum, and be deposited in 
the vagina, where it can remain until the next day, by which 
time it should be renewed. By having a strong thread at- 
tached, it can easily be drawn out. Its presence occasions 
some inconvenience and trouble, as it interferes with the fre- 
quent employment of injections, although it does not prevent 
their use. Chronic enlargement of the nymphae sometimes 
results as a consequence of vaginitis. Leeches, warm fomen- 
tations, and cleanliness will generally remove this difficulty. 

The labia are frequently the seat of abscesses during the 
blennorrhagic affection. A free opening should be made at an 
early period, and they should in all respects be treated accord- 



BLENNORRHAGIA IN THE FEMALE. 181 

ing to the principles of surgery. If the contents of the abscess 
are allowed to find an outlet spontaneously, they are liable to 
pursue a circuitous route, and thus a sinus may be formed 
which will refuse to heal for a long period. I have known such 
sinuses to occur, and to remain more than six months before 
the parts were restored to a sound condition. It is quite sur- 
prising to witness the protracted resistance which, in these 
circumstances, the diseased structure offers to all ordinary 
surgical efforts. 

BLENNORRHAGIA OF THE UTERUS. 

In chronic vaginitis, a catarrhal affection is very commonly 
developed in the uterus. The os, the cervix, and more or less 
of the mucous membrane of this organ, are involved. If an 
examination be made with the speculum, it will be found that 
the follicular or Nabothan glands, and very likely all the parts 
as far as visible, will afford evidence of some abnormal action. 
The inflammation is generally moderate in its type, with some 
induration and engorgement of the cervix ; and vegetations and 
superficial ulcerations are often found to occupy some portion 
of the os uteri or its immediate neighborhood, the mucous 
membrane being everywhere thickened. 

A copious, tenacious, semi-transparent or muco-purulent se- 
cretion escapes from within the os, which is patulous and 
granular, and of a deep-red color. The secretion is the joint 
product of the glands of Naboth and of the internal lining 
membrane of the uterus, and may continue for a very long 
time after all traces of vaginal disease have vanished. The 
sterility of prostitutes, it is generally believed, is due to the 
presence of this discharge, which so frequently exists in this 
class of females. 

In manipulating with the speculum, and in employing a 
sponge or rag-mop for the purpose of removing the stratum 
of thick, vitiated fluid which partially occupies the uterine 
orifice, the parts are easily made to bleed at various points. 
The operator sometimes finds it necessary to pull away the 
abnormal deposit with a pair of forceps introduced through the 
speculum, or to twist it around and entangle it in the swab. In 
a few minutes after being removed, the material can again be 
16 



182 GONORRHCEA AND SYPHILIS. 

seen trickling down the sides of the os tincse and lodging on 
the vaginal surface, where it rapidly accumulates in immense 
quantities. I have frequently witnessed these phenomena in 
women who find their way to Deer Island Hospital, and other 
similar institutions. Dissolute and broken-down prostitutes, 
and those of a strumous or leuco-phlegmatic temperament, are 
liable to this variety of blennorrhagia. The affection gives rise 
to more or less constitutional disturbance. The patient be- 
comes pale, has a poor appetite ; is troubled with indigestion, 
pain in the lower part of the spinal column, attended with a 
sense of weight or bearing down of the uterus ; is unable to 
walk or to take other exercise without aggravating the local 
symptoms ; is nervous, dejected ; has cold hands and cold feet, 
a clammy condition of the skin, a quick, feeble pulse ; is subject 
to fits of hysteria ; and is in all respects a miserable specimen 
of humanity. 

Treatment of Uterine Blennorrhagia. — In the local treat- 
ment of this malady, the application of the solid nitrate of silver 
to the cervix, to the lips of the os tinea?, and in some instances 
higher up within the walls of the uterine cavity, is an effectual 
procedure. Before using the silver, it is requisite to remove 
the morbid secretion, and to cleanse the parts as thoroughly as 
possible by wiping them with soft cotton or lint. Unless this 
preliminary measure be carefully observed, the caustic cannot 
fairly attack the lesion. The employment of the silver should 
be followed immediately by an injection of warm water, or of 
decoction of poppy. It will be necessary to insert the speculum 
in order to bring the parts into view to which the nitrate is to 
be touched. The repetition of this process must depend upon 
the results which follow, and of which the surgeon will best 
judge by introducing the speculum in three or four days after 
the application of the silver. The potassa cum calce is pre- 
ferred by some practitioners, among whom are Bennett and 
Acton. It penetrates deeper into the tissues than the silver. 
It is hard, and requires to be rubbed against the affected part. 
Hysterical convulsions and profuse haemorrhage are among the 
symptoms occasionally supervening upon its use. It requires 
no little practice to know how to apply it to the best advantage. 
Prof. Simpson selects the potassa fusa in preference to all other 



BLENNORRHAGIA IN THE FEMALE. 183 

escharotics. He states that he finds it far more manageable, 
speedy, and certain than any other substance. The chloride of 
zinc is a favorite with some surgeons. It is highly deliquescent, 
and it is difficult to prevent it from spreading in all directions ; 
and before it is possible to employ a solution of carbonate of 
soda, or other neutralizing agent, the caustic will have time to 
injure the healthy parts. Similar objections exist in regard to 
the potassa fusa. If the medical attendant be thoroughly 
drilled in the business, as are the surgeons mentioned above, 
perhaps no fear need be entertained in the employment of the 
zinc or potash ; but otherwise, I think these escharotics are to 
be regarded as too potent, too quick, too unmanageable for com- 
mon use. But few Actons, or Bennetts, or Simpsons are to be 
found in the medical or surgical ranks. The French practition- 
ers are in favor of the acid nitrate of mercury in syphilitic and 
other uterine or vaginal ulcerations. In ordinary cases, it is 
best to begin with the nitrate of silver, or with the compound 
tincture of iodine ; and, failing of success with these, the more 
energetic topical measures may subsequently be adopted. 

In the free use of caustics of almost any kind, the os and 
cervical canal are in danger of becoming contracted to such a 
degree as nearly to obliterate them, and thus interfere with the 
normal process of menstruation. To prevent this accident, it is 
sometimes necessary to pass a bougie through the canal when- 
ever the caustic is resorted to. 

In rare instances, that have resisted the measures above pro- 
posed, deep scarifications into the os have been made, and the 
nitrate of silver applied immediately afterwards with the inten- 
tion of destroying the follicles from which the morbid secretion 
comes. The operation is said by M. Huguier to have been suc- 
cessful in his hands, and not to have been particularly painful. 

Injections. — Under this head a few words only need be 
offered in addition to what has been presented in previous pages 
in connection with urethral and vaginal gonorrhoea. For oc- 
casional use, an intra-vaginal injection of a concentrated decoc- 
tion of black walnut leaves will be beneficial.* The speculum 
is first to be introduced, and the neck of the womb exposed ; 

* This was a favorite remedy with Vidal. 



184 GONORRHCEA AND SYPHILIS. 

then with a large enema syringe, the decoction is to be thrown 
up, in direct contact with the cervix, and a tampon of lint is 
afterwards to be placed upon it so as to isolate it from other 
parts. This injection is to be used only twice a week, and on 
the days when it is not employed, the patient is to make use of 
some of the milder astringent liquids. An infusion of walnut 
leaves, with half a drachm of sulphate of alumina to the pint, 
can be injected every two hours during the day. A decoction 
of the inner bark of the common white pine makes a valuable 
injection in all chronic cases of vaginitis, whether the uterus be 
involved or not. It should be used with a long syringe, in the 
same manner as the walnut infusion. It is slightly stimulating 
as well as astringent, and causes a sensation of warmth in the 
parts, but no other inconvenience. A composition consisting of 
four ounces of glycerine and one ounce of tannin has been em- 
ployed with advantage in chronic vaginal and uterine blennor- 
rhagia. The method is this: after the puriform matter that 
lines the walls of the vagina has been thoroughly washed away 
with cold water injections, two or three plugs of lint, well soaked 
in the glycerine and tannin compound, are to be introduced so 
as to occupy the entire length of the vaginal canal. On the 
next day they are to be drawn out ; the cold water injections 
again employed, and fresh plugs introduced through the 
speculum. 

Various other topical means will suggest themselves to the 
physician, if those already mentioned prove inadequate to ac- 
complish the desired end. 

The Constitutional Treatment best adapted to the condi- 
tion of most patients laboring under chronic vaginitis or uterine 
blennorrhagia, is that which has a large tonic element of some 
sort. The bowels should be kept in a healthy state ; the diet 
should be simple, nutritious, and liberal in allowance ; and bath- 
ing, cold or warm, as the patient may prefer, is to be practised 
every day or every other day, at all seasons of the year. 

URETHRAL BLENNORRHAGIA IN THE FEMALE. 

Urethritis, as a distinct morbid condition, is not often met 
with in the female. If a healthy woman has sexual intercourse 



BLENNORRHAGIA IN THE FEMALE. 185 

with a man while a blennorrhagia is upon him, the vulva, 
vagina and uterus sustain the injury, while the urethra, from 
the almost total concealment of its orifice within the surrounding 
tissues, is comparatively exempt from danger. Nevertheless, it 
is occasionally doomed to receive the contagious matter, while 
the other parts escape. 



Symptoms. — Itching, smarting, pain, scalding, difficulty in 
micturition, with frequent inclination to urinate : redness and 
tumefaction of the meatus, announce the advent of the disease. 
Other unusual phenomena, relating to the parts directly in- 
volved, soon appear. It is scarcely necessary, however, to draw 
an exact portrait of all the minutiae belonging to this variety of 
blennorrhagia in the female. It is sufficient to remark that the 
symptoms are essentially the same as those which exist in 
urethritis in the male. If the physician be in doubt whether 
the secretion proceed from the urethra or the vagina, the ques- 
tion can be decided by passing the finger into the latter, and 
pressing gently from behind along the course of the urethra. 
This will occasion an escape of the purulent fluid from the 
orifice of the urinary canal, if that be the seat of trouble. 



Treatment. — Rest, low diet, fomentations, hip-baths, etc., as 
recommended in the other forms of gonorrhoea in the female, 
will be appropriate in the present variety. Bland, diluent 
drinks are more essential here, and more beneficial, that when 
the urinary organs are not involved. The bladder is prone to 
manifest a great degree of excitability, to allay which the free 
use of opiates will be important. 

The internal administration of balsam of copaiba, cubebs, and 
other anti-gonorrhoeal remedies, may be relied upon with the 
same prospect of advantage as in urethritis in men. If, during the 
acute stage of the complaint, much febrile excitement prevail, 
all specifics for the local affection should be laid aside, until the 
constitutional symptoms have been subdued by antiphlogistic 
measures. To allay the general disturbance, let the patient be 
put upon the use of the following : — 
16* 



186 GONORRHOEA AND SYPHILIS. 

R. Sodns Sesquicarbonatis, gr. xv. 

Potassae Nitratis, 9ij- 

Spiritus iEtheris Nitrici, 5j. 

Vini Antimonii, 5 ij. 

Syrupi Simplicis, 5 ij. 

Aquae Fontanae, § v. M. 

Dose. — Two drachms every hour during the day. 

The liquid acetate of ammonia is a suitable diaphoretic, and 
may be ordered in liberal doses if any febrile symptoms are 
present. 

When there is no great constitutional derangement, and it is 
seldom that there is, the patient must at once be put upon the 
use of remedies that act peculiarly on the urinary organs. 

As a standard prescription, adapted to the greatest number of 
cases in the female, the subjoined formula will be found one of 
the most reliable : — 

R. Copaiba?, 

Mucilaginis Acaciae, 

Pulveris Cubebae, aa, gj. 

Spiritus iEtheris Nitrici, § ss. 

Misturae Camphora^ § viij. M. 

Dose. — Half an ounce, in as much cold water, three times a day. The 
quantity may be increased if the stomach will tolerate it. 

Although a suspension from all active motion is in a high 
degree subservient to the favorable action of the remedies in 
this disorder, and places the patient in a condition to be relieved 
of the local inflammatory engorgement and all its attendant 
symptoms, yet a majority of persons of both sexes who have 
the complaint, are either unwilling or unable to submit to that 
degree of confinement and restraint so indispensable to a 
speedy cure. The advantages of rest are in no disease more 
remarkably displayed than in the acute inflammation of the 
mucous tissues generally. This we see verified in conjunctiva 
itis, in dysenteric and pulmonary affections. The same is 
eminently true of the genital system. On the other hand, let 
this fact be impressed on the patient's mind, — that there is 
no malady in which indiscretions and irregularities of any 
kind are followed by more injurious consequences than in 
blennorrhagia. 



CHAPTER XVII. 

SYPHILIS. 

The researches prosecuted by those who have enjoyed most 
ample opportunities for studying the syphilitic disease, in all its 
phases and consequences, as displayed in the human organiza- 
tion, point almost without exception, to the fact that its primal 
type and characteristic qualities are one and the same. 

The virus has its best expression, its most distinct embodi- 
ment, as well as its earliest incarnation, in the chancre ; and we 
must regard this lesion, with here and there an exception, as 
the starting-point or focus from whence result all the malign 
and diversified influences and developments known to the med- 
ical man as syphilitic. We may consider the fact as established 
beyond reasonable doubt, that in all the varieties of the disease 
there is but one true poison of syphilis, which poison produces 
different effects according to the nature of the tissue and the 
peculiar idiosyncrasy of the constitution in which the disease is 
manifested ; — all these different phenomena depending on the 
same morbific cause. 

It is well known that if several men have intercourse with a 
woman diseased with syphilis, they may not all exhibit precisely 
the same symptoms, although all receive a venereal infection. 
Mr. Acton relates the following : Three students had connection 
with the same grisette during one evening. One was affected 
with a phagedenic sore ; one with an indurated chancre ; and 
the third had a simple excoriation, which was slighter than that 
which existed on the genital organs of the female, who was 
examined a few days after the debauch. Holmes Coote men- 
tions the case of a surgeon who had connection with a female. 
Immediately afterwards he noticed an abrasion on the inner 
surface of the prepuce which he disregarded, but which spread 
into a non-indurated chancre. From the discharge, which was 

(187) 



188 GONORRHOEA AND SYPHILIS. 

purulent, proceeding from an open ulcer, five sores formed by 
inoculation. Of these, only two acquired the characteristic 
induration at the base. Similar instances, exhibiting the most 
varied abnormal conditions, occasioned by the syphilitic virus, 
now and then present themselves in ordinary practice ; and they 
render the complaint in question one of the most obscure and 
difficult subjects to understand that comes within the range of 
medical and surgical observation.* 

Of the essence — the intrinsic nature — of the microscopic 
forms of this animal poison, we know nothing. As yet it has 
proved too subtle for detection. Whatever it may be, in any 
stage of its vitality, it remains shrouded in the same darkness 
that conceals from our comprehension the elementary nature of 
the variolous substance, or the morbific principle of hydro- 
phobia, typhus fever, or cholera. 

Investigations, conducted by competent scientific masters, 
under every possible advantage, have been sufficiently numer- 
ous ; and we have incontestible proof both from natural and 
artificial inoculation of the contagiousness of the chancrous sub- 
stance, and also, as I believe, in some instances, of secondary 
venereal matter ; but we are not furnished with a reliable foun- 
dation, upon which to rest any conclusions in regard to the 
specific, primordial atom, on the presence of which the com- 

* It is plain, that if we admit the doctrine of duality, on which I have just 
dilated, we may do so without infringing upon the unicity of the syphilitic 
poison ; because, from all we have said, it would appear that there seems to be 
a duality of chancrous poison, but that there is but one actually syphilitic virus 
capable of infecting the economy. We, therefore, find that Ricord may side with 
his pupil [M. Bassereau] without interfering with any of the tenets he has hith- 
erto been maintaining. He has, indeed, given in his adhesion, but in a some- 
what guarded manner, and he is, perhaps, right, as certain points are not, as yet, 
perfectly elucidated. Amongst these, is the fact of soft chancres being rarely, 
or never, found in the cephalic region ; about the head and face the chancres are 
always of the hard kind ; and yet it may fairly be supposed that the region in 
question may occasionally come in contact with pus derived from a soft chancre. 
M. Diday has attempted to explain this by saying that soft chancre does not 
take on the head, just as scabies is known to shun the cephalic portion of the 
body. But it must finally be confessed that the evidence in favor of a duality 
of chancrous virus is overwhelming, and that it is very probable that much 
time will not pass before it is admitted by the whole profession. The unicity 
of the syphilitic virus remains, however, unshaken* — Victor de Meric, Esq., 
Lecture — London Lancet, August, 1858. 



SYPHILIS. 139 

municability of the exudation depends. Specimens of indurated 
chancre, at different periods of development, have frequently 
been examined microscopically, with a view to ascertain their 
precise anatomical characters. Mr. Busk, the accomplished sur- 
geon of the Hospital Receiving-ship " Dreadnought," London, 
and M. M. Lebert and Robin, of Paris, have devoted special atten- 
tion to the subject. They have arrived at the same result as to 
the specimens submitted to their observation. The chancrous 
masses were composed of fibrous tissue or stroma, — granular 
albuminous deposit, epithelial cells, blood-globules, free nuclei 
and fibro-plastic cells. Thus it will be seen that these investiga- 
tions respecting the minute structure of chancre, do not add any 
thing to our knowledge respecting the peculiar constituent, or 
entity, which endows it with its mysterious power to pervade, to 
poison, and to destroy the entire human fabric. Fibro-plastic 
cells and fibrous stroma, and indeed all the component parts 
mentioned above as composing indurated chancre, are found 
every day in morbid growths, that are as remote in their nature 
from all that is syphilitic as the east is from the west. We 
must say then, that the microscope reveals the same anatomical 
elements in chancre that are found in other morbid products. 
And this is but repeating the declaration of our ignorance as to 
the diagnostic element — the causative poison of syphilis, — a 
poison that imprints upon the organism results totally different 
from any other. Chancre is the root of this tree of evil. Its 
fruits are seen in generations that live after, the root itself is 
dead. 

Probably not one chancre in twenty possesses the character- 
istic induration of its base and edges and all the other peculiar 
attributes which constitute what is called the Hunterian chancre, 
and which was formerly regarded by many leading surgeons as 
the only true type or indication of the syphilitic sore, and which 
alone, under ordinary circumstances, was thought capable of 
infecting the constitution. Mr. Henry Thompson reckons only 
two primary sores or chancres — the indurated and the soft ; and 
estimates that one instance of the former occurs to three or four 
of the latter. " That this form of disease," says Labatt, " which 
has been termed the Hunterian chancre, is of rare occurrence 
must be admitted. The late Mr. Carmichael, whose experience 
both in hospital and private practice was very extensive, never 



190 GONORRHOEA AND SYPHILIS. 

met with more than half a dozen cases of the disease as described 
by Hunter, during a long period. I have conversed with Sir 
Philip Crampton and Mr. Cusack, our most eminent surgeons in 
this city, and they are unanimous as to its infrequency. On re- 
ferring to the communications with which I have been favored 
by Mr. Lawrence, of St. Bartholomew's Hospital, I find that this 
distinguished and accomplished surgeon is not disposed to 
recognize Mr. Hunter's description of primary syphilis as ade- 
quate or perfect, but considers it both partial and defective." * 
Dr. John C. Egan, of Dublin, who has had an extensive hospital 
experience, states that out of upwards of three hundred cases 
of primary ulcers, the characters of which he accurately noted, 
he was able to collect only thirty which could be strictly classi- 
fied under the head of the genuine indurated and excavated 
ulcer of Hunter. f 

This variety of chancre is more frequently seen in the male 
than the female. It yields but an insignificant quantity of 
matter. 

At the present day, the general opinion of the profession is, 
that primary sores, not endowed with the characteristic sign of 
hardness, have within them the contagious element, and the 
power also, to generate secondary accidents. It is believed that 
the most simple chancres that have the least degree of indura- 
tion, may be followed by constitutional symptoms. The presence 
of induration is* deceptive. This is acknowledged by Ricord 
himself. Some authorities maintain that all chancres are more 
or less indurated. The attribute in question is due to the pres- 
ence of plastic lymph deposited in the diseased tissues, and the 
degree of induration depends upon the amount of infiltration. 
This interstitial effusion is comparatively a late symptom or con- 
dition, superadded to the vesicle, or pimple, or abrasion, which 
constitutes the original lesion, and which is unattended with 
pain or soreness, and progresses very tardily, almost impercep- 
tibly, for a period ranging from five to fifteen days, before the 
distinctive feature of induration begins to be developed, and this 
hardness requires time for its completeness. In some examples, 
the deposition of lymph is so gradual that it does not become 
a well defined and fixed fact until the third week of the chan- 

* Venereal Diseases, 1858 ; p. 90. f Syphilitic Diseases, p. 49. 



SYPHILIS. 191 

crous sore. In most instances, the chancre we are speaking 
of appears as a solitary lesion. It occurs in individuals of the 
highest health. It never passes into a sloughing ulcer, unless 
in consequence of some mismanagement ; and it gives rise to 
no constitutional disturbance whatever. The cartilage-like wall 
which nature throws around the sore, as if to insulate it from 
the surrounding healthy structures for their protection, restrains 
the abnormal local action within circumscribed bounds. But 
this does not prevent the absorption of the virus into the system. 
Induration is not in this respect a protective process. On the 
contrary, there is no variety of chancre so uniformly followed 
by constitutional symptoms as the one under consideration ; 
whereas the syphilitic poison may be, and generally is, destroyed 
by the sloughing or mortification of the part in which it is 
located. Mr. Lee is of opinion that the same result may take 
place from suppuration in an absorbent gland, consequent 
upon ulcerative inflammation ; and also that what is termed 
the deciduous cell-growth, or suppuration on the surface of a 
poisoned wound, will effectually eliminate the poison from the 
part.* That this theory will apply to many primary sores is 
highly probable, and perhaps may help us to understand how 
it is that some primary accidents are followed by secondary 
affections, and others are not. But suppuration of a pri- 
mary sore does not necessarily and always ensure immunity 
from constitutional syphilis. This latter is not an infrequent 
occurrence in the form of cutaneous eruptions, sore throat, 
iritis, etc., supervening upon chancres or ulcers that yield an 
abundant puriform fluid. 

A chancre may be developed upon any portion of the geni- 
tal organs of the male or female. In the former, it is most 
frequently located on or near the orifice of the prepuce, on the 
corona glandis, and at some point near the fraenum. It is occa- 
sionally detected in the urethra, just within the meatus, and is 
known as the concealed chancre. In the female, it is most com- 
monly situated on the external labia, at the line of union cf 
the skin and mucous membrane. It occasionally selects other 
sites, as the entrance of the vagina, the anus, the lips, the nip- 
ple, and very rarely, the cervix uteri ; also different parts of the 
skin adjacent to the genital organs. 

* British and Foreign Med. Chir. Review, October, 1856. 



192 GONORRHOEA AND SYPHILIS. 

The difference in the natural structure of the parts in which 
the chancre is situated, as causing induration, is sometimes il- 
lustrated in quite a curious way. Thus, if one portion of a 
primary sore is situated on the corona glandis, and the other 
on the mucous surface of the prepuce, the induration will 
form at the base of the latter only. The veritable Hunterian 
chancre on the glans penis is a phenomenon that was probably 
never seen. The firm, compact structure of the part, and its 
almost total destitution of areolar substance, form a barrier 
to the deposit of lymph on which, as previously stated, the 
dense cartilaginous chancre in question depends for its char- 
acteristic feature. 

The surface of the chancrous sore is frequently covered with 
a grayish, adventitious layer, which, on being washed away, or 
otherwise removed, is quickly reproduced. This false mem- 
brane has been supposed to be the substance which furnishes 
the poisonous matter. The idea, however, is merely hypothet- 
ical ; for we have examples of chancres showing themselves 
in men after they have had connection with females who have 
at the time no lesion, except the slightest abrasion or excoria- 
tion of a venereal character in some portion of the mucous 
surfaces. 

The venereal virus continues in contact with the part in 
which it is deposited, for a short time, before any effect is per- 
ceptible. This is what is termed the period of incubation. 
The phrase is objected to by Ricord, who maintains that the 
poison, when brought in contract with the tissues, excites in- 
stantaneous action, which remains local for three, four, five, or 
six days, within which time the sore may be destroyed by 
some caustic application, and thus constitutional infection be 
prevented. 

The interval between impure connection and the manifesta- 
tion of local symptoms varies somewhat according to the con- 
dition and anatomical structure of the part in which the virus 
is deposited. If this spot happen to be denuded of its cuticu- 
lar or epithelial covering, inoculation will show itself, without 
doubt, at an earlier moment than it would if there were no 
such abrasion. It is probable, also, that the specific appear- 
ances may be developed more rapidly on the warm, moist 
surface of the mucous tissue than on the external surface. In- 



SYPHILIS. 193 

deed, it is very difficult to inoculate through the sound skin. 
The average time between exposure and the supervention of 
morbid phenomena is between five and six days. The ex- 
tremes, as to this interval, vary from twenty-four hours to 
ninety days. Hunter had one case, where the period of incu- 
bation was seven weeks. Mr. Lawrence relates an instance of 
five weeks ; Mr. Parker mentions two cases, in which the virus 
did not develop itself until three weeks in one, and one month 
in the other. 

ABORTIVE TREATMENT OF CHANCRE. 

If a chancre be destroyed with caustic at an early day, and 
before induration of its base has taken place, the system may be 
saved from infection. The axe has been laid at the root of the 
tree. This is the case, at least, ordinarily. Ricord holds, that 
to be effectual, this local treatment should be resorted to be- 
fore the fifth day from exposure to the contagion. But to 
this it may.be replied, that we cannot know in any given case 
at what precise moment the poison may be received into the 
system. The time when this happens must vary in different 
individuals, and according to the nature of the various tissues 
in which the primary affection is developed ; and in regard 
to the rule suggested by Ricord, as a guide for the rapid 
destruction of the virus, I must say that I am not disposed 
to advocate a rigid adherence to it. If, as the result of con- 
tagion or of a suspicious connection, the virile organ has 
upon it a papule, pustule, abrasion, or sore, which. may be the 
forerunner of constitutional syphilis, the best thing the sur- 
geon can do, locally, is to make a caustic application to the 
spot, provided this can be done seasonably — that is, within 
ten days from the appearance of the abnormal condition. The 
design of this simple operation is twofold : to destroy the 
morbid structure, and to create a healthy recuperative action 
in the part. 

During the first six or eight days subsequent to the devel- 
opment of a pimple, pustule, or sore on the prepuce, glans, or 
elsewhere, I am not aware that it presents any unequivocal, 
diagnostic features or infallible signs, by which the surgeon 
can determine whether or not it is a genuine venereal chancre, 
17 



194 GONORRHCEA AND SYPHILIS. 

according to the Hunterian doctrine. It is far easier to use 
the dialect of the pathologist, and speak of circular forms, ex- 
cavations, hardened edges, and the like, as appertaining to a 
suspicious sore, than it is to demonstrate to one's senses that 
these attributes are or are not present in many lesions follow- 
ing suspicious sexual intercourse. These remarks are applica- 
ble to a large proportion of cases that present themselves for 
treatment. Many well-skilled and practical surgeons, familiar 
with syphilitic affections in all their phases, are honest enough 
to acknowledge the difficulties they encounter in determining 
the precise character of the primary sore. If the parties see 
fit to try the experimeut of inoculation, perhaps the question 
may be settled ; but meantime, if the medical attendant should 
wait for evidence consequent on this procedure before doing 
any thing to rescue the individual under his care from any possi- 
ble constitutional manifestations, he would do an unpardonable 
injustice to the case. 

Amid the absurdities, the fallacious tests, and the uncertain 
indications in which the judgment of the surgeon is vacillating 
and perplexed, how shall he act ? This question can be dis- 
posed of in a summary manner. The circumstances relating 
both to the history and existing condition of the patient, sug- 
gest the suspicion that syphilis may lurk in the diseased organ 
or tissue. Laying aside, then, the nice splitting of hairs, and 
other minor distinctions, let the medical attendant, without 
delay, institute such a rational and practical line of treatment 
as shall best protect the individual from the direful train of 
evils that wait on constitutional syphilis. Of this treatment 
I propose to speak presently. 

Dupuytren was strongly opposed to cauterization. He called 
it the most fatal of methods.' M. Vidal seems also to have en- 
tertained a low appreciation of the efficacy of the abortive 
treatment, whether the knife or the caustic was applied in the 
extirpation of the chancre. He held that a portion of the virus 
may in some instances enter at once into the system, as it does 
from the bite of a venomous reptile ; and that however early 
the local treatment may be put in force, it cannot, in such in- 
stances, act as a safeguard against the occurrence of secondary 
symptoms. The local" action, and that which ultimately con- 
taminates the entire organizations, in the cases here alluded to, 



SYPHILIS. 195 

may be simultaneous. It is "admitted that the destruction of 
chancre at the earliest moment of its existence does not always 
prevent general infection ; and the theory advanced by M. 
Vidal commends itself to our judgment ; and yet the number 
of cases brought to our knowledge of constitutional symptoms 
supervening upon the radical destruction of the primitive chan- 
cre is too small essentially to diminish the merits of such local 
treatment. If the surgeon ' be consulted within eight or ten 
days from the appearance of the suspicious lesion, he is justi- 
fied in resorting to the caustic. Whether the pimple or ulcer 
possesses all the reputed scientific attributes of a chancre, or 
not, the caustic should be applied. It cannot do harm. If 
properly employed, it will occasion a small slough, after which 
follows a simple healthy sore, that will heal kindly, and thus 
the surgeon may prevent a life of misery. 

Syphilographers differ as to the number of days from the 
inoculation of the primary local disease during which it is 
expedient to resort to cauterization as an abortive measure. 
With Ricord the period for this application is very limited ; 
Wilson is less definite, but is evidently inclined to allow more 
latitude, as to time, than Ricord. Mr. Lane states that he 
should be much surprised to find any sore which healed within 
a fortnight of the application of the original poison followed by 
secondary symptoms. It seems rational to suppose that the 
chances of constitutional infection are, cceteris paribus, in pro- 
portion to the duration of the local disease ; and, therefore, the 
earlier we destroy any erosion or pimple induced by exposure, 
the more successful will the effort prove, and the less occasion 
will there be for any special constitutional treatment. In offer- 
ing suggestions for caustic applications, Ricord remarks : " In 
the first place, we are not to reckon the age of the chancre from 
the time when its existence was first perceived by the patient, 
but from the moment of exposure to contagion. In acting 
thus, and destroying the chancre before the fifth day, the pa- 
tient escapes from secondary symptoms." According to this 
method of computing the age of the chancre, and the rule given 
for its treatment, we should scarcely know how to proceed in 
some cases. Suppose the individual does not discover any ab- 
normal condition whatever, until the sixth or eighth day after 
suspicious connection, although he has had a watchful eye upon 
the parts, and suppose he should apply to a physician within 



196 GONOKRHCEA AND SYPHILIS. 

three or four days, or even eight days, from the time the lesion 
was detected, would not the application of the escharotic be a 
justifiable and hopeful measure? I think it would; and I 
imagine few practitioners would refrain from its use under 
these circumstances. 

Local Applications. — The potassa fusa, the acid nitrate of 
mercury, and the concentrated nitric acid, are the remedies 
with which I am most familiar as local appliances used to neu- 
tralize the syphilitic virus, while it is believed to be yet confined 
to the infected spot, or chancrous sore, in the first few days of 
its existence. Either of the escharotic substances here referred 
to is sufficiently potential in its action, and perfectly managea- 
ble in the hands of the surgeon. The nitrate of silver I never 
employ on these occasions, nor yet the Vienna paste. The sil- 
ver does not extend so deeply in its destructive agency as either 
of the other substances, and although it may act efficiently on 
the more superficial portion of the morbid tissue, the deeper 
stratum may, and probably will, escape. "With organic struc- 
tures it forms an insoluble compound, which acts as a prevent- 
ive to its continuous power as a caustic, by producing a hard, 
impermeable coating on the tissue. It thus sometimes acts 
favorably where it is applied to check slight haemorrhage from 
a small surface ; but I quite agree with a remark of Professor 
Peaslee, in his Human Histology : that, although it blackens 
the epidermis, and renders opaque the epithelium of mucous 
membranes, it destroys nothing beneath them, and is, therefore, 
not a caustic in any scientific sense. Some surgeons rely upon 
it ; but it is not entitled to confidence in our attempts to anni- 
hilate an incipient chancre. Ricord formerly employed it ; — 
he now recommends the Vienna paste and the monohydrated 
nitric acid. 

If the lesion consist in an abrasion, the nitric acid is the sub- 
stance I generally apply. It may be used by means of a small 
bit of lint secured to a silver probe. The sore may be freely 
covered with the acid, and any excess must be immediately 
washed off with warm water, which should be at hand for the 
occasion. If the surface, which requires to be touched, be very 
small, the end of a glass rod may be moistened with the escha- 
rotic, and then be brought in direct contact with the diseased 
spot. If the acid nitrate of mercury be preferred, the same 



SYPHILIS. 197 

method must be observed. In three or four days, the slough, 
supervening upon the application, will be detached, and a 
healthy, granulating surface will appear. If a solitary vesicle, 
pimple, or pustule is to be destroyed, I sometimes select the 
potassa fusa. It penetrates deeper than either of the liquids 
above named. The end of the stick of potassa should be re- 
duced to a point, which is to be brought in contact with the 
apex of the morbid growth, in the same manner as in the ordi- 
nary use of nitrate of silver. Or, what is still better, let the 
dome of the pimple be broken with the point of a probe, and 
let it be emptied of its contents before applying the potassa, 
which will thus give freer access to the whole of the diseased 
structure. To ascertain precisely what execution the alkali has 
done, the point of the probe may be used in breaking up and 
removing the debris or portion destroyed. As the operation 
throughout is void of pain, no haste is required in its perform- 
ance ; but caution and exactness are both necessary. The 
potassa is highly deliquescent, and it is difficult to preserve the 
solid stick in a dry state. The surgeon had better place a par- 
ticle of it on the end of a probe, rather than apply the stick 
itself, unless it be perfectly dry. I have tried it with a pointed 
glass rod, or pen, and have never experienced any trouble. A 
drop of vinegar will neutralize any superabundance of the caus- 
tic. The extent of surface destroyed by this corrosive sub- 
stance is about twice as great as it appears to be at the time of 
its application. The same is the fact in regard to the depth to 
which it penetrates, and it will be well for the operator to bear 
this in mind when he is about to cauterize with it. 

A moderate degree of inflammation co-existing with the pus- 
tule or sore, need not deter from the employment of any escha- 
rotic. The risk of increasing the inflammatory tendency is very 
small. Cold-water dressing, or a soft-cracker poultice, may fol- 
low the use of the caustic for two or three days. The water- 
dressing will suffice, and is to be preferred. The patient should 
keep still, and be restricted to a low diet. When separation of 
the eschar has taken place, the sore may be treated with the fol- 
lowing dressing : — 

R. Ferri Potassio Tartratis, 3 ij. 

Aquae Fontanae, § viij. M. 

17* 



198 GONORRHOEA AND SYPHILIS. 

Lint, saturated with this solution, should be kept in contact 
with the sore. Nitric acid, two drops to the ounce of water, 
makes a clean and suitable dressing also. If the purulent dis- 
charge be abundant, the aromatic wine with tannin will be the 
most appropriate application. 

M. Acidi Tannici, gr. xv. 

Vini Aromatici, § iij. M. 

If the sore become painful, a piece of lint, soaked in a solu- 
tion of the aqueous extract of opium, in the proportion of two 
scruples to four ounces of warm water, should be laid upon it ; 
and the warm-water dressing, with an oiled silk covering or 
thin gutta-percha, should be placed on the organ. These topi- 
cal measures are generally adequate to preserve the chancrous 
sore in a healthy condition until a sound cicatrix is formed. 
Slight cases frequently occur, which, after the caustic is applied, 
require little or no further care or treatment. Instances occa- 
sionally present themselves, in which healthy granulations fail 
to appear, after the application of the caustic and the subse- 
quent dressings that have been mentioned. The surface of the 
wound assumes a spongy or fungoid aspect. In such circum- 
stances, the following astringent and tonic lotion will be well 
suited to the lesion : — 

R. Acidi Tannici, • • B j. 

Tincturae Lavandula?, . . 5iv. 

Vinillubri, § iv. M. 

The black wash acts beneficially in ordinary cases of chan- 
crous sores. For many years it has borne the test of surgical 
experience, and its therapeutic qualities are of a reliable char- 
acter. 

As a protection to the sore by night, the nitric oxide of 
mercury ointment should be ordered. 



CHAPTER XVm. 

CONSTITUTIONAL TREATMENT OF CHANCRE. 

Although the surgeon loses no opportune moment in attempt- 
ing to annihilate the syphilitic virus by the destruction of the 
part in which it is believed to be confined, he should not feel 
safe or justified in all cases in dispensing with internal remedies 
as a prophylactic against constitutional infection. 

The chancre, considered abstractly and by itself, is an affair 
of small moment. It is the consequences which may be en- 
tailed upon the individual, and of which the chancre is the usual 
medium, that we are to dread. But if the abortive plan of 
treatment has been seasonably executed, to the extent of com- 
pletely demolishing a chancrous sore, we are warranted, 
generally speaking, in the conclusion that its poisonous element 
is destroyed also ; and a resort to mercurial remedies will be 
uncalled for. Egan advocates the employment of mercury, even 
if the specific ulcer yields kindly to the topical applications ; 
and he considers that the surgeon who undertakes its cure with- 
out the aid of this mineral, is responsible for the constitutional 
symptoms which his ignorance or temerity will in all probability 
induce. He has, however, the candor to admit that if mercury 
be given with a view to cure the indurated chancre, it will not, 
in all cases, prevent the accession of secondary accidents. If 
perfect cicatrization have been accomplished, and the part be 
restored to a normal condition, the patient may, ordinarily, be 
permitted to resume his avocations, provided his general health 
has not in any wise deteriorated during the local treatment that 
has been needful. 

If any functional derangement of the digestive organs exist, 
it should be rectified by the simplest means. The stomach may 
require a tonic, or the bowels an aperient, or some other 
measure may be necessary to quicken the appetite and bring the 
vital organs into more vigorous play. The diet may now be of 

(199) 



200 GONORRHOEA AND SYPHILIS. 

a generous description ; exercise in the open air, ablution, 
regularity, temperance, and such other hygienic habits should be 
enforced as will promote the constitutional welfare. 

It is seldom, however, that an individual who has a chancre, 
applies for aid sufficiently early to render the abortive treat- 
ment of any avail. In his ignorance, the patient has allowed 
the brief period to pass within which this treatment might have 
resulted in perfect success, and he is compelled to enter upon a 
course of general medication as his only hope. The venereal 
poison, in his case, is no longer circumscribed within the limits 
of the small pustule or pimple, which had such a harmless and 
insignificant look to his unpractised eye. It has broken away 
^from its barriers, and has commenced its course through the 
system ; and, if not prevented by judicious means, it will 
ultimately find its way through all the tissues which constitute 
that system. It will do more than this ; it will increase in 
quantity, and will impart its qualities to the blood , " that river 
of life, that wondrous epitome of solids and fluids," and there 
revel and riot during the existence of its victim. How, then, 
shall this infection be arrested ? Let us proceed to answer. 

The virulent matter, although just emerging from a state of 
incubation, and, therefore, scarcely appreciable, or shown by any 
external manifestation, has, nevertheless, stamped upon the 
\patient the syphilitic diathesis,'and we must now consider that 
sliis constitution is contaminated. Under these circumstances, 
the first thing to be done is to put him upon a Regimen that may 
serve, in some degree at least, as a sanitary cordon, and fortify^ 
him to resist the threatened accumulation and encroachments- 
of the poison. 

The second indication which should engage the attention of 
the medical attendant, has reference to the elimination of the 
morbific principle, through the medium of the emunctories, with • 
which the animal economy is endowed, and which are capable 
of being excited into preternatural activity by various remedial ■ 
agents. 

The personal habits of the patient are to be inquired into, ■ 
and whatever in them is prejudicial to health, should be pro- 
hibited. Let me suggest that it is as much the duty and the 
right of the physician to exact an entire conformity on the part 
of the patient to a rational mode of life from day to day, as it 



CONSTITUTIONAL TREATMENT OF CHANCRE. 201 

is to prescribe medicines, witli the expectation that they will be 
taken and employed according to directions. This I say, be- 
cause I know from experience that it is but too often that the 
physician has to encounter strong opposition, if not downright 
obstinacy, when he gives salutary advice touching the daily and 
nightly indulgences of the syphilitic patient. This is the 
ground on which the latter will attempt to make the former 
i succumb to his unbridled proclivities. A few years ago, a Span- 
ish gentleman just arrived in Boston from a foreign port, sent 
for me to visit him at his lodgings at a hotel. I found him in 
bed, and, on examination, discovered a large chancrous sore on 
the prepuce, and a large bubo in the groin, in an inflammatory 
condition, as was also his whole system, as indicated by the 
pulse, skin, tongue, etc. The apartment he occupied was filled 
with the fumes of tobacco. He was smoking, and stated that 
he spent much of his time in this manner. He also spoke of his 
fondness for stimulating drinks. Through an interpreter, I 
signified my disapprobation of his habits, and remarked that 
they would prejudice his recovery, and that if I attended him I 
should expect he would give up his cigars and libations while 
under treatment. He was instantly exasperated, — said he 
would submit to no such restraint from any man, and that he 
wanted nothing further of me. Accordingly I took my hat, 
and was glad that I escaped so safely from this ruffian. 

In all cases, the patient should be induced, if possible, to 
forego the use of tobacco. The saliva, in its pure state, is 
needed to aid in the early stage of digestion. It is scarcely 
necessary to mention that stimulating drinks must be inter- 
dicted ; the diet should be plain, but nutritious. Among the 
articles of food to be allowed, are milk and lean meats, and all 
our native fruits in their season, and in moderate quantities, 
unless some special circumstances in the case contra-indicate 
them. In short, whatever the physician knows will contribute 
to a healthy condition of the organs of digestion and assimi- 
lation, and thereby tend to preserve the normal richness of the 
blood, should be allowed ; all else ought to be denied. 

If possible, the patient should be placed in a healthy resi- 
dence, where he can have the benefit of a pure atmosphere at 
all times, night and day ; he must avoid all extremes of tem- 
perature, should practise daily ablution of the whole surface of * 



202 GONORRHOEA AND SYPHILIS. 

the body and limbs ; and the skin, liver, bowels, and kidneys, 
should be kept in a healthy condition. The importance of 
these hygienic measures will be sufficiently apparent, if we rec- 
ollect that the moment the syphilitic element comes into con- 
tact with the blood, its immediate and constant effect upon that 
fluid is to diminish the quantity of its red globules in a very 
marked degree. M. Grassi, pharmacien-en-chef of the Hotel 
Dieu, has recently made a series of analyses of the blood of i 
syphilitic patients. In simple chancre, it presents no material 
deviation from its physiological condition. In indurated chan- 
cre and secondary syphilis, there is uniformly a diminution of-' 
the blood-globules, and an increase in the amount of albumen, 
but no perceptible variation in the quantity of fibrine. These 
facts are interesting, in a pathological point of view. As will 
be seen below, the iodide of potassium may be resorted to for' 
the purpose, among other things, of restoring the blood to an 
^approximation of its normal constitution, as it is found to exist 
in healthy persons. 

According to the analyses above referred to, the blood of 
patients affected with simple chancres contained the following 
relative proportions of corpuscles : — 







Parts. 




Parts. 


First patient, 


corpuscles, 


140.4 


to the 


1000. 


Second li 


u 


140.4 


u u 


(( 


Third « 


u 


140.5 


a a 


u 


Fourth u 


a 


138.1 


u u 


a 


Fifth 


«< 


133.6 


a a 


a 



In indurated chancre, the proportion of corpuscles, in one 
instance, was reduced to ninety-four parts in the thousand.' 
N This was increased by the iodide of potassium, which was 
N taken for one month. The corpuscles, at the expiration of 
this period, were increased to one hundred and twenty-eight 
parts to the thousand. In one case of indurated chancre, with 
syphilitic spots, the proportion of corpuscles was reduced to 
^forty-eight parts in the thousand. In all the cases examined, 
the outbreak of syphilis was recent ; the above results, there- 
fore, do not represent the state of the blood in the later stages 
of the disease.* This disturbance in the process of haematosis 

* I/Union Medicale, May, 1857. 



CONSTITUTIONAL TREATMENT OF CHANCRE. 203 

is followed more or less rapidly, in different individuals, by a 
corresponding decrease of muscular strength, anaemia, and other ' 
depressing symptoms. By insisting on proper regulations as to 
diet and regimen, the medical adviser will put the patient in 
the most favorable attitude to forestall these adverse conditions, 
and various others of a kindred nature, which might otherwise 
be developed. 

Artificial Syphilization. — The second indication being 
strictly therapeutic in its bearings, introduces for consideration 
the most appropriate constitutional treatment for subduing the 
disease in all its different forms and phases. In Paris and some 
of the other continental cities, chivalrous experiments, in 
numerous instances, have been made within a few years, upon 
men, women, monkeys, and other animals, with a view to test 
not only the prophylactic, but also the curative effects produced 
by inoculating the pus of chancre upon the healthy skin or 
mucous membrane, and thus, it is alleged, ultimately to carry 
this process to the point of saturation in the system, as is done 
in vaccinia. In this way, it is argued, patients may become not 
only artificially syphilized, and ever after be proof against the 
action of the virus, but it is further announced and believed, 
that the symptoms, which follow after exposure to impure con- 
nection, promptly disappear by having the patients artificially 
inoculated on the thighs, vulva, prepuce, abdomen, etc. 

M. Turenne, a young French physician, commenced a series 
of experiments in 1844, or thereabouts, for the purpose of test- 
ing the doctrine of Hunter, on the communicabilty of the vene- 
real virus to the lower animals. After various trials, he at last 
succeeded in causing in monkeys, inoculated with chancrous 
matter, a complaint resembling, in all respects, a true chancre. 
From monkeys it was transferred to rabbits, cats, and horses, 
and from these victimized animals it was returned by inocula- 
tion to the human species. 

Dr. Robert Weltz, of Wiirzburg, having made trial of it on 
himself, produced four veritable chancres on his own person. 
The researches of Turenne led to the curious discovery that 
\each succeeding chancre, from inoculation, became less and 
less, until finally no chancrous sores followed the application of ^ 
the poison. This fact gave rise to experiments on the human 



204 GOXORRHCEA AND SYPHILIS. 

subject, with a view to bring about the condition styled " syphi- 
lization." It is asserted that tire process in question protects 
the organization from the venereal disease subsequently, just as 
an individual who has had small-pox cannot have it a second 
time. To arrive at perfect immunity, the patient must undergo, 
as rapidly as possible, reiterated inoculations, in order that it 
may not jeopardize his health. 

The conclusions drawn by Professor Boeck, of the University 
of Norway, from eighty-four cases which he treated up to 
March, 1856, are that in all cases immunity from the venereal 
virus is obtained sooner or later by inoculation ; that the 
symptoms of syphilis present at the commencement of syphili- 
zation, disappear during the employment of this mode of treat- 
ment ; that the general health does not suffer from syphiliza- 
tion — on the contrary, if the patient has been in poor health 
before inoculation, he most materially improves in strength^ 
and appearance during the process.* 

That the immunity claimed as a result of repeated inocula- 
tions is really acquired, is rendered certain, if we can place 
reliance on the experiments and the testimony, not only of 
Professor Boeck, but likewise on the evidence furnished by M. 
Sperino, of Turin, Danielson, of Bergen, and Carlsson, of 
Stockholm. It is further claimed by some of the advocates of 
syphilization, that it is the only remedy we know ; and that 
the eruptions, the rheumatic and neuralgic pains, and other 
symptoms of constitutional syphilis, vanish under repeated / 
inoculations. 

I opine that the day is far distant when the medical faculty 
of this or any other enlightened portion of the globe will credit 
the idea that the waning health of a human being can be 
restored or benefited by artificial syphilization, as intimated by 
the Norwegian professor. Certain it is, that no human provi- 
dence can calculate or guard against the physical mischiefs that 
might accrue to individuals subjected to this hypothetical and 
Mnsane line of treatment. Instances of the most terrible disas- * 

* Boeck deprecates the use of mercury, which he calls a devilish remedy. 
He holds syphilization not to be merely a local process, acting by derivation 
or by reparative suppuration, but to be analagous to vaccination ; that it fixes 
a certain materies morbi of the body, and renders it latent, but does not 
destroy it. Neither syphilization nor mercury, according to this author, really 
cures syphilis, but only renders it innocuous. 



CONSTITUTIONAL TREATMENT OF CHANCRE. 205 

ters resulting from it have already been reported. Mr. Law- 
rence, of London, states that one of the most troublesome cases 
of phagedenic ulceration of the thighs which ever came under 
his notice, was in consequence of artificial inoculation performed' 
by a physician. Other instances are recorded, in which the 
chancrous sores, manufactured by reckless hands, have refused 
for a long time to heal or amend under any remedial measures. 
It may be that the experience of Turenne and others will in- 
spire hope and courage among libertines and their meretricious 
companions, who hail from the dens of Paris and some of the 
other continental cities, and who may be induced to submit to 
such a style of tattooing and mutilation ; but it is scarcely to be 
supposed that the medical faculty of this country will ever 
countenance such a beastly mode of treatment, — certainly not 
until investigations and experiments shall ripen into higher 
completeness, and the sanative power of the measure has had' 
time to exert a more persistent influence than has yet been dis- 
played in patients who have resorted to prophylactic syphiliza- 
tion. Without entering into any discussion of the real truth 
or fallacy of the doctrines broached by the advocates of artificial 
inoculation, it is enough to say that the demoralizing associa- 
tions and consequences connected with the practice, are suffi- 
cient to consign it to unqualified condemnation. The most 
revolting feature appertaining to syphilization, and the one cal- 
culated to provoke unmitigated indignation, consists in the 
bold, barefaced suggestion that it may be employed as a means 
of safety for persons who are as yet untainted, and who can 
subject themselves to this factitious disease, and ever after be 
shielded from infection, however deeply they may plunge into 
the foul cess-pool of licentiousness and corruption. The next 
step in the march of improvement, peradventure, will consist 
in the internal administration of pure venereal pus, or perhaps 
the mollified crusts of rupia, made into a paste or bolus. This 
would be a fitting climax.* 

* Two physicians have lately been tried in a court of justice in France, for 
practising artificial syphilization on a young boy at a charitable institution. 
The boy had favus, which got well after syphilization was resorted to. The 
court, however, ignored the pretensions of medical science in the case, and 
imposed a fine on the physicians for giving the boy the venereal disease, and 
which he might transmit hereafter to his offspring. 

18 



206 GONORRHOEA AND SYPHILIS. 

The organs composing the emunctory system — that is, the 
x liver, the kidneys, the alimentary canal, the entire circle of the 
mucous membranes, and the skin, with its millions of sudorifer- 
ous and sebaceous glands and ducts — constitute the machinery 
— the channels — through the medium of which the syphilitic ' 
poison can be removed from the animal economy. Although 
the anatomical apparatus we have to work with is situated in 
different portions of the frame, and in structure possesses no 
special homogeneousness or resemblance in its several parts as 
above named, yet as a group, and in respect to function, they 
sustain a close affinity or relation ; and fortunately, in a practi- 
cal point of view, they can be brought to do good service either 
by the same remedial agents, varying in quantity and in the 
modes of administration, or by different remedies so com- 
pounded as to perform a harmonious action, and leading to 
the same practical results. And thus, if a case of constitutional 
syphilis be cured, it is in this way that these emunctory forces, 
inherent in the system, carry away day by day, in homoeopathic 
^quantities, the poisonous element, until the last particle is ex- 
hausted, and the morbid process engendered by its presence is 
brought to its final rest. 

Methods op Treating Syphilis. — Statistics of the various 
modes of treatment that have been pursued, from time to 
time, in different countries, are sufficiently numerous and com- 
prehensive ; and, if the* numerical computation were adopted 
as the basis upon which to form an opinion relative to this or 
that method of cure, all parties might claim success, and even 
triumph, for their cures are reported in figures running up to 
thousands and hundreds of thousands. And if we can rely 
upon human testimony, we are compelled to admit that the 
venereal disease, in all its forms, can be cured in more ways 
than one, — that is, either with or without mercury. 

Of the great variety of remedies that have been arrayed 
against the malady under consideration, probably no one has 
encountered more formidable enemies, fought harder battles, 
or achieved more signal victories, than mercury. During the 
last hundred years, the fortunes of this article in the materia 
medica, like the fortunes of some men, have been somewhat 
checkered. At one period it has enjoyed the sunshine of favor 



CONSTITUTIONAL TREATMENT OF CHANCRE. 207 

throughout the medical world ; at another, it has been doomed 
to fall into disrepute, and to give place to the vaunted claims 
of various rivals, which, in turn, have lived out their brief day 
of popular notoriety, and then dropped into the grave with the 
pall of oblivion upon them. And now, again, it may be said 
that the medicine in question has been resuscitated, Phoenix- 
like, from its ashes : for at the present day it is regarded by the 
chief savans in the profession, not perhaps in the light of a spe- 
cific antidote to syphilis, as it once was, but as indispensable to 
its best management in a great majority of cases ; and the sta- 
bility of its popularity, as it is now considered and modified, 
can scarcely be questioned. 

It seems but fair, in this connection, that the substance of the 
experiments that have been tried, for the purpose of testing the 
claims of the mercurial and non-mercurial treatment of syphi- 
lis, should be stated. This will be done with all convenient 
brevity. 

Some years ago, the results of two thousand cases occurring 
in two years, in the British army, were reported under the su- 
pervision of the late Sir James McGrigor. These were all rep- 
resented as cases of primary syphilitic ulcers on the penis, and 
were reported as cured without mercury. The average length 
of time required for the non-mercurial course to complete the 
alleged cures, where no buboes existed, was twenty-one days ; 
for those with buboes, forty-five days. From these results, it 
would appear that primary venereal sores can be cured without^ 
mercury, and in a shorter period than when that mineral is 
used. But, while this statement has been made by the advo- 
cates of the anti-mercurial treatment, they at the same time 
acknowledge the utility of mercury under certain circum- 
stances, and admit that some cases prove obstinate unless this 
remedy is employed. When these peculiar cases are likely to 
occur can never be known beforehand by the medical attendant. 
It would therefore seem to be wiser policy to anticipate them in 
the onset, by the timely and careful use of mercury, rather than 
trust to a code of practice which may not in all cases secure the 
desired results without an appeal to some mercurial preparation. 

In 1828, experiments instituted by Dr. Fricke, in the Ham- 
burg General Hospital, were first made public. In four years, 
out of one thousand six hundred and forty-nine patients of both 



208 GONORRHCEA AND SYPHILIS. 

sexes, five hundred and eighty-two were treated with a mild 
course of mercury, and one thousand and sixty-seven without 
mercury. The mean duration of the latter method was forty- 
one days, and that with mercury eighty-five days. Dr. Fricke 
states that relapses were more frequent, and secondary accidents 
more severe, where mercury was given. He observes, also, that 
Mie has treated more than five thousand patients without it, and 
has still to seek cases in which that remedy may be advanta- 
geously employed. 

In 1833, the French Council of Health published the reports 
sent in by the physicians and surgeons attached to regiments 
and hospitals in various parts of France. Some of these reports 
were in favor of the mercurial method, others adverse to it. 

From various published documents, embracing more than 
80,000 cases, Professor Bennett, of Edinburgh, regards it as 
established that primary syphilis is cured by what is termed 
Hhe simple treatment more readily than by any other, and with 
4ess probability of the occurrence of secondary symptoms. He 
considers that the diminution in late years of the frightful sec- 
ondary and tertiary accidents, which were so common many 
years ago in Scotland, is to be attributed to important revolu- 
tions in practice ; and he is inclined to award the credit to the 
non-mercurialists, and, so far as relates to the treatment of the 
venereal disease, he belongs to that class of practitioners. His 
views, however, of what constitutes the mercurial treatment 
appear to be different from what the present mode of practice 
would seem to sanction. He remarks that this treatment con- 
sists in keeping up a slight salivation, at least, for the space of 
a month. , Such a mercurial course would doubtless, in many 
cases, be well nigh as destructive to the patient as the malady 
which it was intended to cure, and no wonder that Professor 
Bennett and others object to it. But this is not the method 
that is advocated or practised at the present day by any intelli- 
gent mercurialist. Indeed, the very term mercurialist, in the 
signification attached to it thirty years ago, is perfectly obsolete 
in this country, at least. The word was applicable to a class 
of practitioners who flourished some half a century since, and 
are now dead. 

It has not only been demonstrated that all syphilitic manifes- 
tations, whether primary or secondary, may be removed without 



CONSTITUTIONAL TREATMENT OF CHANCRE. 209 

the aid of mercury, but also that, in some cases, the work is 
accomplished in a shorter period where this substance is not 
prescribed. Ricord treated with mercury two hundred and 
ninety-two men, and, without mercury, five hundred and 
ninety-eight. It required forty-two days, on an average, to 
cure the former, and only twenty-eight days the latter. Thus 
it appears that the use of mercury delays the healing of the 
primary lesion by one third the period required when that 
mineral is not employed. It is admitted, however, that, in 
v cases accompanied by much induration, the administration of 
mercury materially shortens the duration of the chancrous sore. 
With regard to the greater or less frequency of secondary 
symptoms, after the removal of the primary accidents, treated 
with the use of mercury or without it, I am persuaded, from 
reliable evidence thus far adduced, that such symptoms are 
more frequent in cases where mercury has not constituted an 
essential part of the remedial course. I am unable, however, 
to credit the statement of Mr. Bacot, who says that secondary 
symptoms occur in the proportion of one case in ten where no 
mercury has been used for the cure of the primary affection ; 
whilst, on the contrary, the proportion of such cases is only one 
in seventy-five where that remedy is employed. Would that 
this statement in all its particulars were true, but the history 
of syphilis, as now seen, does not correspond with the remark 
of Bacot. The proportion of cases in which consecutive lesions 
appear is much greater than he mentions. " I cannot agree," 
says Erichsen, " with the statement that secondary symptoms 
are less frequent after the simple than after the mercurial treat- 
ment of syphilis. I have seen the non-mercurial plan, of treat- 
ment very extensively employed at the University College 
Hospital : indeed, it was formerly almost invariably practised 
there, more particularly in the syphilitic cases occurring among 
out-door patients under the late Mr. Morton, who strongly advo- 
cated it ; and I have repeated occasion to observe the frequency 
with which it was followed by secondary symptoms. In private 
practice, also, I have had considerable opportunities of compar- 
ing the two methods ; and I can safely say that I have seen the 
simple treatment more frequently followed by secondary symp- 
toms than the mercurial plan has been when properly and 
judiciously employed." 
18* 



210 GONORRHOEA AND SYPHILIS. 

The advocates of the simple treatment are doubtless correct 
in the idea that mercury has no specific effect upon the syphi- 
litic poison, but that it acts, like other remedies, as an altera- 
tive, by increasing the amount of secretions and excretions ; 
and thus, we argue, that it favors the elimination of the vene-^ 
real virus. Although I am far from believing that the mer- 
curial preparations justify all that has been advanced in their 
praise, I am by no means disposed to discard them from the 
catalogue of our most useful remedies in the treatment of 
various syphilitic affections. I employ them as valuable and 
important additions to the simple plan of treatment. I have 
faith in them ; but it is a modification of .the faith, which, 
thirty years ago, ruled and misguided medical practice far and 
wide. For the cure of indurated chancre they are almost in-*- 
dispensable. But great circumspection is demanded in their 
administration. Their influence upon the general condition 
of the patient, as well as upon the disease, cannot be too care- ' 
fully watched. In many cases it is undeniable that mercury 
aggravates all the symptoms. One of the earliest and most 
frequent forms of syphilis, in which it is mischievous, is the 
non-indurated chancre or ulcer, the cure of which it tends to 
prevent by altering the system in such a manner as to favor ^ 
the progress of ulceration, rather than arrest it; and it can- 
not in any way protect the patient from secondary accidents 
under these circumstances. It is well known, also, that mer- 
v cury will sometimes induce ulcerations sui generis. The fault, 
however, is not always in the medicine, but, rather, in the 
manner of prescribing it. 

In the treatment of patients of well-known scrofulous dia- 
thesis, or in whom any peculiar susceptibility to the action of 
mercury exists, it is generally an easy matter to regulate the 
dose so as to meet this peculiarity, provided it is certain that 
the remedy is demanded. But the mere fact that any idiosyn- 
crasy does even exist in tjie patient, should deter from the use ^ 
of any mercurial agent, except in the mildest form, in the most 
cautious manner, and as wholly subsidiary to other therapeutic 
measures. 

In all instances where there is a tendency to sloughing, 
whether in a primary chancrous sore, in a bubo, or in any of 
the later affections, the mineral of which we are now speaking 



CONSTITUTIONAL TREATMENT OF CHANCRE. 211 

ought to be regarded as injurious, if not absolutely dangerous, 
to the patient, and therefore inadmissible. It is not my pur- 
pose, however, to set forth, in this place, a full specification of 
the circumstances and conditions of the syphilitic patient, 
which render the administration of this potent remedy, in 
any form or combination, judicious or otherwise. Occasions for 
speaking more explicitly will necessarily occur with sufficient 
frequency, as we proceed to a consideration of the various acci- 
dents that will present themselves for treatment. 

In the selection of mercurial preparations for internal use, 
every practitioner is more or less partial to some particular 
formula. The blue pill and the hydrargyrum cum creta are 
preferred by some of the most substantial English surgeons 
and physicians. The protochloride, the bichloride, the iodide, 
and the biniodide, have likewise their advocates. Mr. Wilson 
and Dr. Egan are in favor of the blue pill. The latter writer 
recommends that gentle ptyalism be maintained for several 
weeks; but I feel warranted in stating that the leading prac- 
titioners in this country do not sanction or follow such ad- 
vice, whatever they may have done in years gone by. The 
blue pill is easily managed. One at night, for five or six nights, 
either with or without a small quantity of opium, according 
to the irritant action of the pill upon the bowels, will answer. 
After some half a dozen pills have been taken, one may be 
given in the morning also, or every other morning. This 
cautious proceeding, which is recommended by Mr. Wilson, 
should always be observed for the first few days, whatever be 
the form of mercury selected for use, because its effects upon 
the system have not yet been ascertained ; and if any peculiar- 
ity exist, it will readily be discovered. If the hydrargyrum 
cum creta be preferred, the proper dose will be three grains, 
which are about equal to five grains of blue pill, twice a day. 

It was once considered important to provoke the salivary 
apparatus to copious ptyalism in order to obtain the greatest 
benefit from the mercurial treatment. The medical men of 
the old school probably never felt in a more jubilant mood than 
on those occasions when they witnessed the flowing streams 
set in motion by the potent magic of calomel, administered by 
their own hands. More recently, the opinion has prevailed 
that a constant, although moderate, soreness of the gums is 



212 GONORRHOEA AND SYPHILIS. 

all that is necessary. These two methods seemed to be based 
on the theory that the morbid effect of the medicine upon the 
healthy tissues, must precede its salutary action on the dis- 
eased structures ; whereas, it will appear evident, if we care- 
fully watch the influence of the mercury upon the symptoms, 
that if the amendment take place at all, it commences before 
the gums become red and tumefied. The remedy produces 
the good before it does the harm. We can now take a retro- 
spective view, and see that in the treatment of the disease 
with mercurial preparations, the various mischiefs which have 
been inflicted upon the gums, the teeth, the buccal mucous 
membrane, the salivary glands, and even upon the constitution 

■itself, were unnecessary and barbarous. Had the prudent 
method of Erasmus Wilson been adopted half a century ago, 
the prejudice against mercurials would never have existed — a 
prejudice which had its foundation in the evil practice of giv- 
ing the mineral in question with a recklessness which seems 
almost incredible, and which, if pursued at the present day, 
would be almost suicidal to the medical men who should coun- 
tenance it. This treatment, to which was usually joined a 
process of semi-starvation, was called heroic. It was so with 
a vengeance. Fortunately for the poor wight who has syphilis, 
a more enlightened and auspicious epoch in the career of 
medicine has arrived ; and the action of mercury, and its abso- 
lute value in subduing certain symptoms, arising from the 
syphilitic virus, are now better understood. Implicit faith in 
the power of this therapeutic agent no longer exists in the 
ranks of the medical profession ; and since it has been their 
custom to prescribe it in fewer cases and in vastly less quan- 
tities than formerly, the venereal disease has ceased to commit 
such terrible ravages on the human organization. It need not 
be repeated that in the administration of mercury it is never 
requisite or desirable to salivate. The venereal poison cannot 
be drawn into such an unnatural current, and through this be 
piloted out and disembogued from the system. The patient 

^cannot spit out the disease. To attempt its elimination by es- 
tablishing an artificial drain through the salivary apparatus, 
would be like beating the air with a feather with a view to 
expel from it the miasm of yellow fever. In both cases, the 
poison is endowed with a sort of ubiquity ; in the one, pervad- 



CONSTITUTIONAL TREATMENT OF CHANCRE. 213 

ing the human constitution ; in the other, that of the atmos- 
phere. 

The ultimate point to which we should ever push the use 
of mercury, is, merely to increase the redness of the gums; 
and this increase in the vascularity of the capillaries of the 
mucous membrane, should be regarded as a warning to with- 
hold the article entirely for a few days, or else to employ it in 
very much diminished quantities. 

In some instances, persons, who have doubted their ability 
to take mercury in any form or quantity, on account of the 
facility with which they imagined ptyalism would occur, have 
been prevailed upon to make trial, with the promise given to 
them, that the moment any special physiological effect is dis- 
played in the condition of the gums or breath, the medicine 
will be discontinued ; and in scarcely a single instance has the 
apprehended evil or disability been realized. In prescribing 
mercury, nothing is gained by being in a hurry. On the con- 
trary, by a little patience, the physician will rarely fail to 
manage the patient in a manner that will not disturb the sys- 
tem, which can gradually be brought to tolerate the medicine 
to the extent required, not only without inconvenience, but 
with all desirable comfort and advantage. If received into 
the stomach in connection with the meals, it has appeared to 
be borne more quietly than when taken under other circum- 
stances ; and it is not improbable that by accompanying the 
food, being incorporated with it through the different stages 
of digestion, and mingling with it in its progress to be trans- 
formed into blood, and finally gaining access to the most 
minute ramifications of the tissues, it permeates the entire 
organization more freely than it otherwise would. I therefore 
always direct the patient to take it immediately after eating; 
and when this rule is observed, it produces no pain, griping, 
or other trouble in the alimentary canal, — considerations of 
no small importance. The late Mr. Babington recommended 
that mercury be used as here mentioned. Of course it cannot 
be regarded as part and parcel of the aliment of the economy ; 
and yet it fulfils a purpose scarcely subordinate to it in the 
circumstances requiring its employment, for it serves as a sub- 
stitute, and sometimes more than an equivalent, for any other 
medicinal substance. When properly administered, it acts as 



214 GONORRHOEA AND SYPHILIS. • 

a benign and safe alterative upon the skin, kidneys, liver, and 
gastro-pulmonary mucous tissue simultaneously. Does not this 
effect upon the emunctory system afford a solution of its modus 
operandi in the cure we seek to accomplish ? And does it not, 
without any forced or far-fetched argument, justify and com- 
mend its use ? It is not simply because two poisons cannot 
exist in the system at the same time, as was first broached by 
the sagacious Hunter ; but because it stimulates to greater 
activity the different eliminative organs, between which nature 
has established a consent or unity of functional labors. 

The mercurial practice has now become venerable with age, 
and a cloud of witnesses, both among the living and the dead, 
and of the highest distinction in the profession of medicine, 
might be adduced to testify to its efficacy ; but such a marshaling 
of names is uncalled for ; nor is it necessary at this day for any 
man to enter the lists as a special champion in its defence. 

In commenting upon the use of different mercurial prepara- 
tions, I have made no particular allusion to the external em- 
ployment of the /mercurial ointment. Formerly, inunction was 
a prevalent method of subduing venereal symptoms. In later 
years, this plan has been to a great extent laid aside, in this 
country at least. It is still regarded by some of the most 
eminent German physicians and surgeons as preferable to any 
other treatment. Professor Carl Sigmund in a recent publica- 
tion, says : " While we write these lines, the result of the 
records of cases [at the Vienna Hospital] from the year 1842 to 
1855, lies before us. 9,379 cases treated by the external use 
of mercurial ointment as here laid down, justify the statements 
which we have just made. . . . Our observations have been 
verified by patients from all professions and all ages, and in 
all the five parts of the world our followers have confirmed 
these observations, in cases without number. We, therefore, 
think ourselves authorized in asserting that until a remedy 
equally good or better shall be pointed out, mercury, and above 
all, mercurial ointment externally, is to be preferred to all other 
remedies. " Professor Hebra, of Vienna, agrees with Sigmund as 
to the superiority of mercury, and particularly of the ointment. 

It has already been remarked that the malady under consid- 
eration has, ordinarily, its initial development in chancre. But 
it does not stop here. Its tendency is to pursue an aggressive 



CONSTITUTIONAL TREATMENT OF CHANCRE. 215 

course ; and when not disturbed by the interference of the 
surgeon or physician, it describes a cycle of phenomena, — 
primary, secondary, and tertiary, — with great regularity, just 
as we witness in variola, vaccinia, or rubeola, except that its 
different evolutions and periods require months or years, instead 
of days, for their completion. But if the patient has undergone 
medical treatment, the normal series in the chain of successive 
manifestations is frequently broken, and the symptoms are 
developed in an irregular manner. For instance, the use of 
certain drugs may keep at bay the secondary accidents, but not 
annihilate the syphilitic diathesis, and a train of tertiary affec- 
tions, over which the treatment has exerted no control, may 
appear. Such instances every now and then present themselves. 
In more particularly presenting the plans of treatment, it will 
be advisable to speak of the disease separately in the three prin- 
cipal pathological stages, into which syphilographers Lave agreed 
to divide it. These several stages or forms, namely, the primary, 
the secondary, and the tertiary, have each their individual and 
well-marked characteristic features, which, for the most part, 
appear in uniform, chronological order, and with almost mathe- 
matical precision ; and as chancre claims priority, it will be the 
theme for consideration in the next chapter. 



CHAPTER XIX. 

CHANCRE. 

Of the primary sores, there are several varieties. The in- 
durated form first claims our attention. It is generally admit- 
ted by surgeons that as soon as a chancre has become indurated 
— which usually takes place during the first week or two — and 
is the true, classical, Hunterian chancre, the disease cannot be 
regarded as any longer a purely local affection ; and the proba- 
bility is that the abortive treatment can do the patient no good. 
For this, the golden opportunity is lost. Cauterization and 
caustics are, under ordinary circumstances, excluded from the 
list of curatives ; and if thought of at all by the practitioner, it 
is only that he must say of them to the patient, — it is too late 
for their successful employment ; for induration is almost a 
certain proof that the system is contaminated. Ricord believes 
that to this rule there is no exception, and that it is the 
prerogative of indurated chancre, alone, to impregnate the 
system. Upon this latter point, however, there is not a uni- 
formity of opinion. Facts are almost daily brought to light in 
the history of syphilitic patients, which totally contravene the the- 
ory that an individual, who has secondary symptoms, must have 
had an indurated chancre at some former period.. The doctrine 
so strenuously insisted upon by Ricord, is not sustained by the 
observations of other authorities, who are entitled to be heard 
on this subject, and who do not confine the origin of constitu- 
tional syphilis exclusively to indurated chancre. I refer to the 
teachings of such men as Vidal, Wilson, Lane, Sigmund, Trous- 
seau, and Velpeau. In my own practice, several instances of 
secondary accidents, in adult subjects, have occurred, in which 
the parties were totally unconscious of having had primary 
disease. Of this I am certain. Is it possible that in each of 
these cases a concealed chancre existed ? If so, it must have 
healed spontaneously, and without causing enlargement of the 

(216) 



CHANCRE. 217 

inguinal glands. This supposition, to me, seems unreasonable. 
Some of the cases to which I here refer, will be related in con- 
nection with secondary affections. 

The indurated chancre is rarely followed by a suppurating 
bubo, although tumefaction of the inguinal glands usually takes 
place on both sides, — not, however, in all instances, as stated 
by some writers. Some years since, I saw a case of indurated 
chancre in a patient of Dr. John Homans, of this city. The 
glands on the right side, only, were involved. Consecutive 
secondary and tertiary symptoms supervened and lasted for a 
long period. In the early part of March, 1857, a married man 
came under my care for a large chancrous sore, situated on both 
sides of the frsenum, and implicating this membranous fold, 
which was finally destroyed by ulceration. Four chancres, of 
veritable Hunterian type, next appeared upon the external 
surface of the prepuce near its border ; and subsequently, a 
chancre formed upon the abdomen, by accidental inoculation, 
just below the umbilicus ; and lastly, one on the dorsum 
penis, — also by inoculation from the patient himself, — near 
the pubes, — making a total of seven chancres on this man. 
The healing of these primary lesions consumed more than five 
months' time. During the early period of the first sore, a bubo 
of medium size came in the left groin, and remained six weeks. 
The other inguinal region continued in a perfectly normal state. 
The treatment for this patient consisted, internally, of bichloride 
of mercury in pill, and for external dressings, the black wash, 
aromatic wine, and weak chlorinated water, and the nitric oxide 
of mercury ointment. Blisters were applied over the tumified 
inguinal glands. 

Although there is no specific for the cure of any syphilitic 
affection, I feel justified in saying that for indurated chancre 
mercury is the surest and safest remedial agent we can employ. 
Its salutary operation in obliterating the induration without 
detriment to the system, is now acknowledged, almost without a 
dissenting voice, in the highest circles of the profession. But 
let us be sure that we have an indurated chancre to cure, before 
we prescribe this remedy. The particular form which may be 
chosen, is not a matter of very great importance. In certain 
cases, each preparation may have its advantages or disad- 
vantages ; but both are to be regarded as mere casual circum- 
19 



218 GONORRHOEA AND SYPHILIS. 

stances, that are not inherent in the medicine. The submuriate 
is quick and rather harsh in its action ; but in cases of iritis, 
where there is no time for delay, and where a mercurial has 
been determined upon, it is particularly appropriate. It is less 
valuable and less called for in indurated chancre. It is more 
liable than the other mercurial salts to disturb the bowels and 
debilitate the system to a greater degree than is desirable. 

Plethora, and an anaemic condition of the patient, are both 
unfavorable for the advantageous exhibition of mercury. In 
the former case, before commencing with this article, it will be 
best to reduce the system by a spare diet for three or four days, 
and by the use of a moderate saline laxative, after which the 
mercurial treatment will be admissible. If the patient be pale, 
feeble, and wanting in constitutional vigor, mercurials should be 
dealt out in the most sparing manner, if at all ; and given in 
connection with some ferruginous medicines. Of these, the tar- 
trate of iron and potash is by far the best. Whenever a tonic is 
required, as an adjuvant to mercury, the following is entitled to 
precedence above all others : — 

R. Ferri Potassio Tartratis, § j. 

Aquae Fontanse, § viij. M. 

Two teaspoonfuls of this solution may be taken three times a 
day in a decoction of quassia prepared as follows : — 

R. Quassiae Rasurae, B xij. 

Div. in chart, No. vj. 

Steep one parcel in a pint of water for an hour. Strain the 
decoction, and let a gill of it be taken with two drachms of the 
above ferruginous solution. 

An ounce of the potassio-tartrate of iron, of ordinary samples, 
is as much as can conveniently be dissolved in eight ounces of 
cold water. There is quite a difference in the solubility of this 
salt as prepared by different chemists. Specimens which I have 
seen and used from Messrs. Morson & Son, of London, I think 
are superior to any other. One ounce of their preparation will 
readily dissolve in six ounces of water. 

The citrate of iron and quinine makes a good tonic also, and 
may be taken in conjunction with any of the mercurial salts, if 



CHANCRE. 219 

the individual find it inconvenient to make use of the first men- 
tioned chalybeate. The citrate may be given in pills of four 
grains each, of which three may be taken per diem. Should 
constipation be induced, it may be counteracted by the occa- 
sional use of syrup of senna, by eating freely of fruits, and by 
other suitable diet. If the blue pill be selected, as a general 
rule one may be taken at night with the fourth of a grain of 
opium, and one in the morning without the opium. Should the 
patient become costive in consequence of the opium, then the 
morning pills may be given in the evening as well as in the 
morning. On the contrary, if the bowels are relaxed, the opium 
is to be taken in the morning as well as at night. With this va- 
riation in the pills, the mercury may be continued until the sore 
has disappeared and the hardness of its base subsided, unless 
symptoms arise that indicate an approaching ptyalism. This, in 
substance, is the plan proposed by Professor Wilson. The ben- 
eficial action of the remedy is usually manifested in a few days. 
The average time which the indurated sore requires for passing 
through its different stages, before cicatrization is fully accom- 
plished, is, under favorable circumstances, four weeks. During 
the mercurial course, the patient should be carefully watched, 
and be kept from all exposure to inclement weather. 

Ricord is partial to the proto-iodide of mercury for the cure 
of the Hunterian chancre. This preparation is perfectly man- 
ageable with most persons, and may be prescribed according to 
the subjoined formula : — 

R. Hydrargyri Proto-Iodidi, 3 ij. 

Extracti Hyoscyami, 5j« 

M. Ft. pil. No. xl. 

Give one pill at night. At the end of a week, two pills per 
diem may be ordered, one in the morning and one at night. 
The good effects of the medicine are observed in the condition 
of the induration, which diminishes in extent and hardness ; 
the discharge consists of well-elaborated pus ; the surface of the 
sore presents a clean, healthy aspect, is covered with granula- 
tions, and a cicatrix is soon formed. These results follow when 
any of the preparations of mercury act kindly. The patient 
should continue one pill, or half of a pill, each day, for two or 
three weeks after the induration has disappeared. The absolute 



220 GONORRHOEA AND SYPHILIS. 

quantity which may be requisite in any given case, is to be 
determined, not only by the cicatrization of the lesion, but also 
by the perfect resolution of the induration, which is the last 
abnormal condition to yield. 

Some authorities recommend not to employ mercury during 
the first few days after the appearance of the induration. The 
object of this delay is to ascertain if nature will not remove the 
hardness, and thus prove that it is not of a specific character. 
If a man present himself with a sore having a hard base, this 
sore being the result of a suspicious connection had a few days 
previously, the temptation to prescribe mercury at once, is very 
strong, provided the practitioner designs to trust to this remedy 
at all ; and yet, the advice to defer the employment of mercury, 
is good. The induration may be like that met with in acne, and 
not the persistent, cartilaginous mass, which constitutes the floor 
of the true Hunterian chancre. It has already been stated that 
the form of indurated ulcer described by Hunter, as having a 
hard base, with a margin terminating abruptly, and not extend- 
ing itself into the adjacent tissues, is seldom met with. 

In carrying out the general rule that mercury should be 
given as long as the induration continues, and even longer, the 
practitioner must not forget that in some protracted cases, the 
mass may consist of something more than specific induration. 
It may be composed of organized tissue, which cannot be re- 
moved or acted upon by the mercury, however long persisted in. 
This fact has been confirmed by Wallace and others. Persons 
have been known to bear traces of induration for years after a 
course of mercury has been discontinued, and yet no secondary 
symptoms have followed. It is evident, therefore, that the direc- 
tions given by some writers, for the administration of mercury 
so long as any hardness remains at the bottom of the chancrous 
sore, or where this sore was, are not to be implicitly observed. 
Out of thirty cases reported by Dr. Egan, the induration passed 
away in twelve, after moderate salivation. In the remaining 
eighteen, it persisted for an indefinite period after the effects of 
mercury had ceased, notwithstanding which, no symptoms of 
constitutional infection were observable, although many of this 
class of patients were detained in hospital a long time in the 
anticipation of such an occurrence. 

Those who give preference of the proto-iodide over othei 



CHANCRE. 221 

forms of mercury, claim for it that it will not only cure the 
local disease, but that it will likewise, in a majority of cases, 
secure the patient from secondary symptoms ; or, if secondary 
affections supervene, they will be of a mild type, and the con- 
stitution, not being injured by the previous use of the medicine, 
will bear it a second time, if need be, not only with impunity, 
but with every advantage. The same may be said, however, in 
regard to any mercurial preparation, with equal truth. If ad- 
ministered properly, there is no danger ; their abuse is the evil 
to be avoided. 

There is one preparation of mercury — the bichloride — 
which, for more than three quarters of a century, enjoyed the 
confidence of the most distinguished members of the profession 
in this country and in Europe for the cure of syphilis, but which, 
of late years, and without any good reason, has fallen into 
desuetude in some quarters. In the constitutional treatment of 
indurated chancre, and indeed of all specific symptoms, Drs. 
David Hosack, and John W. Francis, of New York, during the 
most brilliant period of their professional career, were accus- 
tomed to employ this salt to the exclusion of every other mer- 
curial. 

Of the merits of the bichloride, Dr. Hosack says : " In the 
constitutional disease called syphilis, as a general rule I have 
found the internal preferable to the external use of mercury, 
and the mercurial salt, which, from experience, I recommend as 
combining most advantages, and as agreeing best with the 
greatest number of cases, is the corrosive sublimate, or the 
oxymuriate of mercury. This salt, either in the form of pill or 
solution, I have uniformly employed in the cure of syphilis, not 
only when the disease may have been recently contracted, but 
in the most malignant form which it assumes, when it has been 
neglected or injudiciously managed. A valuable auxiliary will 
also be found in the decoction of the lignum guaiaci and the 
radix sarsaparillse as powerful alteratives. Here I cannot but 
protest against the salivating system by friction with mercurial 
ointment and the use of calomel, so commonly had recourse to. 
It is true that these forms of exhibiting the article very soon 
affect the system ; but it is no less true, that when mercury 
exerts its influence upon the salivary glands, in proportion as 
19* 



222 GONORRHOEA AND SYPHILIS. 

this influence is manifested, it ceases to operate upon other 
excretions of the system, and consequently is less active in 
eliminating from the body the poison of the disease. Salivation, 
it is now well ascertained, is wholly unnecessary in the treat- 
ment of syphilis, and the knowledge of this truth cannot be too 
extensively circulated in a country, where, notwithstanding the 
respectable state of medical science, many of the most pernicious 
errors of some of the older practitioners, are still sedulously cul- 
tivated. I am aware that in certain of the public hospitals of 
Great Britain, as well as of the United States, the corrosive sub- 
limate is rigidly prohibited for the cure both of the primary and 
secondary stages of lues venerea ; but it deserves to be recol- 
lected that tins form of mercury still retains, throughout the 
European continent, the high celebrity it acquired long since as 
an anti-venereal. In the venereal hospital of Paris, the largest 
and one of the best conducted establishments of Europe, the 
corrosive sublimate is the only form of mercury employed ; and 
Professor Cullerier, after the most ample experience at this 
charity, knows not an instance of failure with this remedy, or 
one in which it has produced injurious effects." 

I will present the views of Dr. Francis, as expressed in an 
Essay published in the Medical and Philosophical Register some 
years since : — 

" Among the principal advantages which the corrosive sub- 
limate possesses over every other preparation of mercury, are, 
that judiciously administered, it is particularly mild and safe in 
its operation ; will admit of more extensive use in all the 
various forms of lues venerea, and subject the patient to fewer 
inconveniences ; that it enters readily into the general circu- 
lation, becomes miscible with the several fluids of the body, 
the soonest arrests the progress of the complaint, and elim- 
inates the morbid matter through those emunctories of the 
body best calculated for that purpose ; that it supersedes the 
necessity of salivation by its action on all the secretions, and by 
promoting, especially, the cuticular discharges and the evacua- 
tions from the kidneys ; that it is the only preparation to be 
depended on in those peculiar habits of body so susceptible to 
become salivated by every other form of mercury now in use ; 
that in its ultimate effects upon the constitution, it is attended 
with comparatively no injury. These facts are indeed truly 



CHANCRE. 223 

important, and many of them are granted by those who 
altogether reject the use of this preparation.'' 

One hundred years ago, the bichloride of mercury was admin- 
istered in the right way ; and its power, as manifested through 
the skilful use of it by the celebrated Locker, chief surgeon to 
the Venereal Hospital of Vienna, has not been surpassed by 
any article employed since his day. He states that he cured 
4,000 cases of syphilis, in different forms, with the corrosive 
sublimate alone, and without inducing salivation, or any un- 
pleasant constitutional effects. These cases were all treated 
between the years 1754 and 1762. 

A late number of the London Lancet, referring to the 
oxymuriate of mercury, has this expression : " The bichlo- 
ride is borne better than any other form of mercury, and 
can be continued with safety longer than any other mercurial 
preparation."* 

If the bichloride was ever entitled to the confidence of the 
profession, it is worthy of that distinction now. Time has not 
impaired its therapeutic qualities, — time has not modified the 
nature of the venereal poison, nor has a change come over the 
organization of the human system. The three are the same now 
that they ever were, — a like immutability in regard to them 
must always remain ; and the same relations and the same 
influences must always subsist between them. And it is certain 
that all the anti-venereal qualities, which belong to any of the 
modifications of mercury, or to any of its combinations with 
other ingredients, exist in the greatest simplicity, uniformity, 
and purity, and in an eminent degree, in the corrosive sublimate. 
" One would naturally suppose," says Hunter, " that the sim- 
plest preparation is the best, — that which is easiest dissolved in 
the animal juices, does least mischief to the stomach or general 
health, and is least disturbed or hindered in its operations ; 
for we can hardly suppose that any substance joined with mer- 
cury, which alters either its chemical or mechanical properties 
out of the body, can add to its power in the body, excepting a 
substance which had a similar power when acting alone." 

The names of the two American physicians, who have just 
been mentioned, are among the most eminent that ever 
flourished in the annals of medicine in this or any other coun- 

* Lancet, 1857, p. 581. 



224 GONORRHOEA AND SYPHILIS. 

try ; and their opinion is most important evidence in favor of 
the remedy now under consideration. The practice of Dr. 
Hosack, as set forth in the preceding extract from his writings, 
of administering the oxymnriate of mercury for the cure of all 
forms of constitutional syphilis, was almost precisely the same 
as that followed by Dupuytren at the Hotel Dieu of Paris, where 
the oxymuriate was long in vogue as a favorite anti-syphilitic. 
Employed in the careful manner indicated by our distinguished 
countryman, it was doubtless superior in efficacy to any other 
method known in his day ; and on the authority of his great 
name, the same course was pursued by the leading practitioners 
of this country in the management of the venereal disease in all 
its stages. But now a different policy reigns. The use of mer- 
cury is very much confined to the treatment of indurated 
chancre ; and if prescribed for secondary affections, it is, in 
many cases, as an auxiliary to other medicinal agents, rather 
than as the sole or leading one. 

The most convenient way of administering the bichloride is 
in the form of a pill, combined with an equal quantity of the 
muriate of ammonia: — 

R . Hydrargyri Chloridi Corrosivi, 

Ammonia? Muriatis, aa, gr. xvj. 

Aquae Destillatae, 3iss. 

Solutioni addatur, panis medul. sic. q. s. — Ut fiat massa, in pil. cxxviij. 
dividenda. 

This formula gives one eighth of a grain of the corrosive 
sublimate to each pill. The quantity can therefore be regulated 
with the greatest precision for daily use. One pill morning 
and night in immediate connection with the meals. In five or 
six days one pill may be taken three times a day. Should the 
patient be of a delicate constitution, two pills per diem may be 
sufficient to produce the desired result. Some individuals, 
especially females, complain that they cannot take pills. In 
such cases, the annexed prescription can be directed instead of 
the preceding : — 

R. Hydrargyri Chloridi Corrosivi, 

Ammonias Muriatis, aa, gr. vj. 

Tincturae Cinchonas Compositas, § ij- 

Aquae Fontanae, § iv. M. 



CHANCRE. 225 

The dose is one drachm morning and evening for one week ; 
afterwards, three drachms each day, directly after eating. 
When the bichloride has been taken for twelve or fifteen days, 
it is frequently judicious policy to omit it for four or five days, 
and then resume it as before. 

Patients with indurated chancre, whether accompanied with 
bubo or not, should continue the bichloride for several weeks. 
In ordinary cases, there is no occasion for those rigid pre- 
cautionary measures in regard to diet and regimen, that are 
recommended by some authorities ; nor need the patient suspend 
his usual avocations from the mere fact that he is using the 
mercury. But very likely there may be other circumstances 
relating to his condition, which would render it improper for 
him to be abroad. Indeed, a man or woman, with an indurated 
chancre, will usually find the sick chamber the most appropriate 
place during treatment, be that treatment what it may. Among 
the objections of Professor Bennett to the mercurial remedies, is 
this : that the patient must be kept within doors, and submit to 
a variety of other restrictions, not required by the simple treat- 
ment. But every candid mind will admit that under any 
treatment, the patient will recover more rapidly, and will meet 
with fewer drawbacks and impediments, if he be kept as quiet 
as possible ; and his course of living should be regulated 
according to his constitution. For stout, athletic individuals, 
of sanguineous temperament, a spare diet and a slightly anti- 
phlogistic treatment for a few days, are indicated, before com- 
mencing with the oxymuriate ; for with such patients there is 
occasion to guard against local inflammatory action ; but for the 
feeble, the lank, the lymphatic, who, perhaps, are already suffering 
from defective nutrition, such a regimen and such a process of 
reduction would be prejudicial. For the latter class of patients, 
a generous diet, and the" employment of mild tonics, in conjunc- 
tion with the mercurial, will be productive of the most desirable 
effects. Whatever measures may be calculated to rectify any 
abnormal condition of the system, should be put in requisition. 
It frequently happens that an impaired state of the constitution, 
or some actually coexisting complaint, is the direct cause of 
the complications that accompany an indurated chancre. 

While the patient is taking the bichloride or any other 
kindred preparation that may be selected, he will derive advan- 



226 GONORRHOEA AND SYPHILIS. 

tage from the use of saponaria officinalis. It is commonly 
known by the name of bouncing' bet, or soapwort. It is used 
extensively by the German and English physicians as an alter- 
ative, in connection with mercury. It is regarded by them as 
superior to sarsaparilla. The two may be used together in the 
form of decoction, of which a pint may be taken daily. 

Among the various substances which have been employed in 
conjunction with mercurial remedies, the lignum guaiaci and 
the radix sarsaparillae hold a high rank among many of our 
most distinguished practitioners ; and, from experience of their 
use for many years, I can add my testimony in their favor. I 
am aware that some physicians and surgeons consider that they 
should be discarded from the catalogue of remedies. Such an 
opinion, it seems to me, must be the offspring of ignorance, not 
of practical knowledge. It is justly claimed for the two 
ingredients before us, that when combined, their salutary oper- 
ation, associated with the judicious employment of mercurials, 
in the cure of indurated chancre, has been uniformly evinced in 
the most satisfactory manner ; and the compound decoction of 
•guaiacum and sarsaparilla has for years been a favorite drink 
with patients having any syphilitic complaint, whether recent or 
of long continuance. It is prepared thus : — 

ft. Guaiaci Ligni Rasurae, 

Radicis Sarsaparillae Fissae, aa. §j. 

Coq. in aqua fontan. lb. ij. ad lb. j. 

Of this decoction, the above quantity is to be taken, warm, in 
the course of twenty-four hours. Although its effects are to be 
attributed chiefly to its action as a diaphoretic and diuretic, yet 
it is a medicine of no mean value in sustaining the vigor of the 
constitution.* Diaphoretics and diuretics, taken liberally, are 

* Mr. Travers, speaking of sarsaparilla, remarks : — "Its power is most ex- 
traordinary ; more so than that of any other drug with which I am acquainted. 
To regard it as inert, as a mere diluent or an offensive nutrient, is either a proof 
of a very limited experience, or a very prejudiced observation. It is, in the 
strictest sense, a tonic." 

The late Dr. James Johnson, of the London Medico-chirurgical Review, en- 
dorsed the views of Mr. Travers, as the following sentence will show : — " To 
consider sarsaparilla as an inutile lignum — a thing no better than sawdust — 
appears to us to be the acme of prejudice, the wild, fanatic skepticism of a 
book-learned theoric." 



CHANCRE. 227 

calculated to dilute the virus, while they at the same time 
arouse the different depurating organs to increased action ; and 
thus the morbid element is conducted out of the animal economy 
faster than it is formed. Were not this the fact, how else could 
the disease ever be eliminated ? The mere presence of mercury 
and other drugs in the tissues and fluids of the system would 
not neutralize or annihilate the poison. In the language of 
Dr. Graves, " syphilis and mercury are not like two opposite 
forces, not like an acid and an alkali, so that by putting them 
together you are sure to neutralize them. No ; it is a melan- 
choly fact that the constitution may be impregnated with both 
at the same time." Something must be done through the 
agency of the remedies we employ to stimulate the emunctory 
apparatus to greater activity than is required when the individ- 
ual is in a state of health, or he can never be delivered from 
the enemy that exists within him. Hence the advantage of 
using, in the very beginning of constitutional treatment, various 
decoctions and diluents as freely as possible, without injuriously 
affecting the ordinary functions of the system. From the 
moment an indurated chancre has established itself upon any 
part, no matter where, the constitution is probably impregnated 
with its virus as positively as it can be at any future period, 
although, in regard to the quantity of the morbid matter, time 
is doubtless requisite for its increase. The virus is cumulative, 
and its ultimate bounds we cannot fully anticipate. But it 
would be unwise for the physician to wait until he witnessed the 
vitiation of the blood and the other fluids, or the death and 
exfoliation of the bones, or the skin here and there dissolving in 
ulcerated patches, before resorting to other medicinal agents as 
auxiliary to the mercurial treatment. 

Of all the various remedies which have hitherto been, or are 
now, employed for the cure of indurated chancre, I am disposed 
to regard mercury, when judiciously administered, as entitled to 
bear the palm. Induced by the example of Dr. Hosack, sus- 
tained as it was by the profession generally, I was early led to 
prescribe it in the form and manner recommended by him, and 
have never had occasion to doubt its efficacy or safety. I have 
never induced salivation to the slightest degree with the oxymu- 
riate pill. As a general rule, I direct the patient to prolong its 
use for four or five weeks after the specific sore and its charac- 



228 GONORRHOEA AND SYPHILIS. 

teristic induration have disappeared ; and to eke out the treat- 
ment for a still longer period with the potassio-tartrate of iron. 
Ricord advises a daily mercurial dose that shall produce a 
sensible physiological effect for six months. But such a pro- 
tracted course seems uncalled for. I once had a patient, who 
was a medical gentleman, who took the proto-iodide of mercury, 
according to Bicord's formula. He resided at a distance, and 
continued the medicine beyond the time allotted. A long and 
severe salivation ensued, greatly to his detriment. This accident 
is the only instance of the kind that has ever happened to an 
individual who has taken any mercurial by my recommendation. 
But, notwithstanding the value I attach to mercury in the treat- 
ment of the indurated chancre, I am not disposed to make it a 
hobby, — that is, to confide in it to the exclusion of other 
measures. There is a more excellent way, and that way is to 
combine it with some of the adjuvantia that have been mentioned. 
They will always be found important, even in the management 
of indurated chancre, although they are less demanded here, 
perhaps, than in the secondary and still later periods of syphilis. 
In regard to the amount of drinks for daily use, the judgment 
of every sensible practitioner will offer, with sufficient clearness 
and accuracy, all proper suggestions. So, also, in reference to 
mercury, the medical adviser must be the judge as to the 
quantity any individual case may require, in order to realize the 
most favorable effects; and this quantity will be most satisfac- 
torily ascertained by commencing with a small dose, and increas- 
ing it cautiously, until the desired change is experienced in the 
lesion, for which it is given. Surely the surgeon need not be 
told of the ever-varying differences and peculiarities that are 
constantly met with in connection with this disease, and with the 
employment of mercury ; and that no absolute rules can be laid 
down as to the quantity or form of the medicine, that may be 
best for the case in hand ; — nor will any medical man of obser- 
vation and reflection allow himself to be wedded to any exclu- 
sive system, or to be governed wholly by arbitrary prescriptions. 
It should be borne in mind, however, that the quantity of mer- 
cury, which we are always compelled to give for the cure of 
indurated chancre, has a direct tendency to impair the vigor of 
the stoutest frame. Like opium, strychnine, and many other 
drugs, it will kill as well as cure, if, in the exhibition of it, it ba 



CHANCRE. 229 

abused. It is, therefore, the imperative duty of the medical 
attendant to prescribe it with due circumspection, and to fortify 
the patient against all mischief from it. To this end, recourse 
should be had to tonics, — of which, for syphilitic patients, 
the potassio-tartrate of iron is the best. 

Local Applications. — As a constant dressing during the day, 
nitric acid, in the proportion of two drops to the ounce of water, 
will be found convenient and well suited to the condition of the 
sore. Bits of lint should be saturated with it, and applied to the 
diseased surface. The lint must not be allowed to get dry ; but, 
without being disturbed, should be moistened by means of a 
camel's hair pencil dipped in the lotion. If the lesion be on the 
external surface of the prepuce, a piece of thin gutta percha 
should envelop the parts to prevent evaporation. At night, the 
nitric oxide of mercury ointment must be substituted for the 
wash. A weak solution of the French chloride of soda, the 
aromatic wine, with an equal portion of rain-water, a solution of 
potassio-tartrate of iron, in the proportion of a drachm to eight 
ounces of water, — are all entitled to favorable remembrance 
as suitable topical remedies. The black wash, so long known to 
all practitioners, is likewise valuable in many cases. Occasion- 
ally it brings out a vesicular eruption upon the adjacent integu- 
ments, and, when this happens, its employment will do harm. 

In changing the dressings, delicacy of manipulation should 
be observed. The minute vessels of the chancre are easily 
ruptured, and will bleed, and the normal healing process will 
thereby be interrupted. In the minor surgical attentions be- 
stowed, let me be permitted to say that everything that borders 
on unnecessary rudeness, or carelessness, or indifference to the 
comfort or feelings of the patient, should on all occasions be 
studiously avoided. 

Salivation. — If this unfortunate accident happen from the 
use of mercury, the physician will probably have the mortifica- 
tion of seeing the disease, for which the medicine was given, 
assume a retrograde course ; for two poisons, instead of one, 
are now preying upon the system. And we need not wonder at 
the expression of Hunter, that there are now and then appear- 
ances, which occur under the treatment, that will at first 
20 



230 GONORRHOEA AND SYPHILIS. 

embarrass the practitioner. " I have," says he, " suspected 
that mercury, flying into the mouth and throat, has sometimes 
produced sloughs in the tonsils, and these have been taken for 
venereal. " 

The patient requires the most gentle management. In some 
peculiar idiosyncrasies, the factitious disease presents a very 
serious and formidable aspect, — becomes chronic, and produces 
deep and unhealthy ulcerations in the tongue, cheeks, gums, and 
elsewhere within the mouth and throat ; gangrene may set in, 
and the death of the patient be the final result. It is well 
for the young practitioner to be apprized of all these possible 
events. 

Treatment. — At this crisis, the chlorate of potash will ren- 
der essential service. In the most alarming cases of stomatitis, 
its restorative powers have been abundantly tested. A drachm 
of the salt may be dissolved in a pint of water, and taken in the 
course of the day. It may likewise be prescribed as a gargle, 
in about the proportions here mentioned. 

It is better to order a gargle of moderate strength, which can 
be resorted to with freedom, rather than a more potent one, 
which can be employed only two or three times in the day. If 
ulcers exist in any part of the mouth, they will generally in a 
very short time exhibit evidence of improvement under the 
action of the chlorate. The beneficial influence of this salt, 
in all forms and stages of the affection, is unsurpassed by any 
plan of treatment that has yet been adopted. 

The muriatic acid likewise makes a valuable topical applica- 
tion. It should be used once daily, with a bit of soft sponge, 
and the mouth be immediately cleansed with warm water. The 
acid is a favorite with Mr. Acton. He says it never fails. I 
have tried it, and can add my testimony in its favor. It is not 
safe to trust the patient with it. 

The Rhus Glabrum. — An infusion of the inner bark of the 
root of this shrub, commonly called smooth Pennsylvania su- 
mach, is a remedy highly extolled by Dr. William M. Fahnes- 
tock.* It may be recommended as a gargle in every stage of 
the disease. Dr. F. states that when the surface of the mouth 

* Vide American Journal of the Medical Sciences, No. ix., p. 61. 



CHANCRE. 231 

and throat is irritated, it acts most beneficially as a mucilagi- 
nous refrigerant, astringent, and soothing application. I have 
never tested this article ; but the respectable authority, on 
which its employment is brought to notice, entitles it to favor- 
able consideration. Dr. F. regards the infusion as almost a 
specific in the sore mouth attending inordinate mercurial sali- 
vation. 

The tongue is liable to become swollen in a manner seriously 
to interfere with respiration and deglutition. In such cases, it 
will be necessary to apply two or three leeches to the dorsum or 
lateral regions by means of a suitable glass tube. This method 
of abstracting blood is preferable to making incisions into the 
organ. Ulcers occasionally form on the under surface of the 
tongue, near its edges, where the latter come in contact with 
the teeth. These ulcers are attended with a sensation of smart- 
ing and burning pain, and are thus a source of great trouble to 
the individual. To remedy this state of things, a piece of soft 
lint should be soaked in a very weak solution of tannin, or in 
chlorinated water, and placed between the tongue and teeth. 
This is the best protection the case will admit of, and should 
never be neglected. 

So long as salivation is excessive, it will be important to keep 
the alimentary canal in a free state by saline laxatives. Tonics 
and a generous diet will be required, and the patient should 
occupy a large and well-ventilated apartment. 



CHAPTER XX. 
MASKED CHANCRE. 

When a chancre is situated in the urethra, in the vagina, or 
upon the os tincae, it is called the concealed or masked chancre. 
It is this chancre upon which supervene, sooner or later, these 
consecutive symptoms that were formerly supposed to have their 
origin in blennorrhagia ; and hence the latter affection was be- 
lieved to be a genuine syphilitic malady by some medical prac- 
titioners and syphilographers. 

A chancre may exist at any point of the urethral canal 
between the external orifice and the bladder. The most fre- 
quent site, however, is just within the meatus ; and, by everting 
the lips, the lesion may be brought into view, and the diagnosis 
clearly made out. But when the sore occupies a deeper portion 
of the canal, its presence is not so easily detected. The exist- 
ence of a chancrous ulcer in some portion of the canal may be 
suspected when, in a case of blennorrhagia, the discharge does 
not appear until a late day after suspicious connection, — when 
it is intermittent, and occurs at irregular intervals, and is vari- 
able in character, being sometimes thin, scanty, and sanious, 
and at other times thick and profuse, or presenting a tenacious 
slough, similar to what is cast off from the indurated chancre in 
its ulcerative stage. 

Sometimes a whole month elapses from the time of the last 
sexual exposure before the appearance of any abnormal dis- 
charge, which arises from the urethral sore. The other signs, 
which will aid in the diagnosis, are the presence of a distinct 
induration at the spot where the chancre is concealed, which 
can be felt on pressure with the finger. The conditions and 
symptoms here stated do not obtain in uncomplicated gonor- 
rhoea. But if the chancre be too deeply seated within the 
canal to admit of inspection, inoculation may be resorted to 
as a test. It must, however, be tried at an early day, before 

(232) 



MASKED CHANCRE. 233 

the sore has lost its specific character ; that is, while it is ex- 
tending, and before it begins to heal. If a real chancre exist, 
the matter introduced beneath the cuticle will be likely to give 
rise to a true chancrous pustule, and thus all doubt will be 
removed. But the patient may not apply until after the pro- 
gressive stage has passed away, and then the characteristic pus- 
tule cannot be raised by artificial means. Another obstacle 
may be in the way of obtaining an accurate knowledge of the 
pathological condition of the urethra. The patient may object 
to any experiments, and the surgeon will be thrown back upon 
his own ability to decipher the true import of the urethral 
symptoms as best he may. It sometimes happens that the 
sore, resulting from inoculation, is far more difficult to heal 
than the original chancre ; and hence, although the experiment 
as a test of primary syphilis, is valuable, it is a question 
whether it is justifiable. Does not the surgeon expose the 
individual to evils which he knows not of? Fortunately for 
all parties, urethral chancre, either in the male or female, is 
rarely met with. Instances have been known where gonor- 
rhoea and chancre have been contracted during the same impure 
connection. 

The variety of chancre now under review sometimes gives 
rise to very serious mutilations. If it be at the orifice of the 
urethra, it may occasion contraction of that portion of the 
canal, so as to require the long-continued use of small bougies 
or plugs to prevent closure of the meatus, or to expand it, 
and restore the part, in some good degree, to its normal condi- 
tion. Sometimes, when the chancre is seated at a distance 
from the entrance of the canal, it causes, on healing, a trouble- 
some traumatic stricture, which is by no means easily cured. 
In other instances, the ulcerative process extends through the 
entire parts, and perforations take place, usually immediately 
behind the glans penis ; and large portions, even of the ure- 
thra and of the bladder, are destroyed, the patient dying in 
consequence. 

If a primary chancre or ulcer be situated in the vagina or 
upon the os tineas, the fact can be ascertained by means of the 
speculum. When there is such a lesion, the exudation, which 
it yields, consists chiefly of a slight muco-purulent, muco- 
sanious, or ichorous discharge, which irritates the neighboring 
20* 



234 GONORRHOEA AND SYPHILIS. 

parts ; but otherwise the patient experiences no great trouble 
from it, unless it attains a large size. She then complains of 
severe hypogastric and lumbar pains, a sensation of dragging 
weight in the pelvis, etc. But the mere fact that a discharge 
exists, under suspicious circumstances, justifies the medical 
attendant in proposing the introduction of the speculum. 

Treatment of Concealed Chancre. — If the chancre is at 
the aperture of the urethra, local applications will form an 
essential part of the treatment. The weak nitric acid lotion, 
or the black wash, as already mentioned, may be kept upon the 
part by means of lint. For ordinary dressing, either of these 
will answer. Should the ulcer show a tendency to extend 
around the entire circle of the orifice, the application of strong 
nitric acid will be required. If the morbid process can be kept 
in check, so as not to embrace the whole of the orifice, contrac- 
tion, to any great degree, will not be likely to result. A short 
wax bougie, worn for an hour or two, morning and night, while 
the patient is in bed, will be useful in maintaining the normal 
size of the opening. 

If it be ascertained that a chancrous sore has formed at a 
distance from the meatus, local remedies may, even here, do 
much for the patient's advantage. Injections of the chloride of 
soda — one part to twelve of water — must be ordered every 
hour during the day, for a few days. Afterwards, let aromatic 
wine, in the ratio of one part to two of warm water, be substi- 
tuted, or a weak solution of the potassio-tartrate of iron — say, 
one drachm -to ten ounces of water — can be employed with 
safety any number of times during the twenty-four hours. Mr. 
Langston Parker recommends an injection of warm olive oil, 
three times a day, and in the intervals the following solution of 
tannin and opium : — 

R. Acidi Tannici, gr. x. 

Extracti Opii, gr. ij. 

Aquae, §j. 

M. Fiat Lotio. 

A thin shred of lint, soaked in this lotion, may be introduced 
into the passage, being removed when the patient has occasion 
to urinate. 



MASKED CHANCRE. 235 

If serious local inflammation should be present, measures 
are to be adopted at an early moment to subdue it by appro- 
priate antiphlogistics. If possible, the patient should have the 
benefit of a warm bath morning and evening. If only one 
can be administered let it be in the evening. The bath will be 
important, not only in reducing the force of inflammatory 
action, but will allay the nervous irritability of the system, 
which is exceedingly liable to show itself at such times. If 
the chancre exist within the urethra of the male, he is apt to 
be visited with nocturnal erections. To prevent these, the 
physician cannot do better than prescribe large doses of lupu- 
lin, or direct a combination of camphor and hyoscyamus, 
thus : — 

R. Camphorge, gr. xviij. 

Extracti Hyoscyami, gr. xij. 

M. ft. pil. No. xij. Dose. — One or two pills at bedtime. 

The patient must be restricted to a rigid diet, and be allowed 
copious draughts of warm diluent drinks ; he should have a 
moderate saline laxative every second day ; be kept in bed, and 
free from excitement, until the active, inflammatory symptoms 
have been subdued. It will then be proper to put him cau- 
tiously upon a mercurial course of treatment, which is to be 
prosecuted as in ordinary cases of indurated chancre situated 
externally. The blennorrhagic symptoms, if dependent on a 
concealed chancre, will cease, of course, when the chancre 
heals. On the contrary, if the urethral discharge proceed from 
a different cause, the foregoing treatment will prove inadequate 
to its removal. The complaint is a gonorrhoea, and the patient 
must be put upon the ordinary course for this malady. 

If the os or cervix uteri, or the vagina, be the seat of chan- 
cres, their cure will be essentially forwarded by the application 
of the concentrated nitric acid, or the acid nitrate of mercury. 
Either of these substances may be employed every second or 
third day. Another local remedy is the chloride of zinc : — 

R. Zinci Chloridi, 9ij. 

Aquae Fontanee, § xvj. M. 

An ounce of this solution is to be injected three times during 



236 GONORRHOEA AND SYPHILIS. 

the twenty-four hours. In regard to constitutional treatment, 
it is to be conducted on the same general principles applicable 
to similar accidents in the male subject. 

The infrequency of indurated chancre of the os uteri may be 
judged of from the fact that Dr. Egan did not meet with a single 
case during his attendance at the Lock Hospital of Westmore- 
land for four years. This hospital is exclusively for females. 



CHAPTER XXI 

INFLAMMATORY CHANCRE. 

This is the simple venereal sore assuming an inflammatory 
character, and the latter condition may manifest itself at any 
period of the accident. Sometimes the pain, swelling, and other 
concomitant symptoms arise very suddenly, and increase with 
great rapidity ; and, if not arrested, gangrene and sloughing will 
take place in the course of four or five days, or even in less 
time. Where the physician or surgeon is consulted at an early 
day, and adopts a careful and judicious line of treatment, this 
form of chancre is rarely seen. The state of things implied by 
the term inflammatory chancre, is generally induced in conse- 
quence of some irritating or caustic substance too freely applied, 
to the simple sore or chancre, in the haste to destroy it. 

Patients of irregular habits and of sanguineous temperament 
commonly furnish the raw material for the variety of chancre 
treated of in this chapter. Comparatively few cases are met 
with at the present day. Some years since, I saw a specimen on 
a young man who had been under the care of an apothecary for 
the cure of a simple chancre. The abortive method was tried ; 
that is, the apothecary attempted the destruction of the sore 
by applying a saturated solution of nitrate of silver. It was 
employed daily, until a most intense inflammation was excited y 
and rapidly extended, notwithstanding every effort to arrest its 
progress. Phagedena and sloughing supervened, and the pa- 
tient was compelled, as a last resort, to submit to amputation 
of the penis. He suffered for a long period from secondary 
disease, but finally recovered, and has since been remarkably 
corpulent. He had led a dissipated life. 

Treatment. — In the treatment of the patient, the ordinary 
principles of surgery for subduing inflammatory action must 
be our guide. Rest in a horizontal position is indispensable. 

(237) 



238 GONORRHOEA AND SYPHILIS. 

Without the strictest observance of this, all our efforts will be 
unavailing. It is better for the patient to be in bed, than to try- 
any other method of keeping the horizontal position. If he un- 
dertake to lounge about upon a sofa or couch, with his clothes 
on in the usual manner, he will fail to secure for himself the 
advantages implied when we speak of the recumbent posture. 
The warm bath should be taken daily. The patient may be 
allowed orangeade and other refrigerant drinks ; moderate 
saline aperients and the usual antiphlogistics are to be relied 
upon, until the inflammation is subdued, and the lesion brought 
into a healthy condition, which can be accomplished without 
difficulty, provided the medical attendant can maintain perfect 
command over the habits of the individual. 

The late Mr. Key, of Guy's Hospital, had a high opinion of 
the cold infusion of sarsaparilla in lime-water, as a constant 
drink. Its power of allaying irritability of action, both local 
and constitutional, he regarded as incontestible in this and all 
other forms of constitutional syphilis. Irritability of the system 
is sometimes one of the most intractable symptoms to manage, 
and shows itself in quite a variety of ways, sometimes in the 
condition of the cerebral organs, sometimes in the state of the 
bowels, sometimes in palpitations of the heart ; and at other 
times the functions of all these organs are strangely deranged, 
while the local symptoms remain at a high point of intensity. 
In such circumstances, the patient should be kept under the 
influence of opium. There is no remedy that will so speedily 
and so kindly minister to his relief as this. It should be 
employed early ; that is, the moment he begins to complain of 
restlessness and inability to obtain sleep. If he has had a bad 
night, he will in the morning report himself as exhausted ; and 
an aggravation of all the symptoms will be almost certain to 
ensue on the following day. Large doses of opium will not only 
allay the general irritability of the system, but will assuage the 
inflammation and pain which complicate the local accident. 
Whether the solid gum be employed, or the tincture, or the 
sulphate of morphia, is of minor consequence. Two grains of 
opium should be given every three hours, until a decided im- 
pression is manifested ; and this impression may be sustained, 
if necessary, for several days without interruption. When the 
influence of the opium is effectual in procuring refreshing sleep, 



INFLAMMATORY CHANCRE. 239 

and inducing and maintaining a genial state of the mental 
powers, an improvement in the condition of the chancre will 
soon follow; and, whatever other appliances may be employed, 
the opium is entitled to the credit of exerting an important 
agency in bringing about the amendment. Sometimes, where 
large quantities of this narcotic are taken for several successive 
days, the bladder loses its expulsive energy to such a degree as 
quite to alarm the patient. In such cases it will be advisable 
to omit its use for the time being ; and the patient will need a 
warm bath or two, and perhaps the catheter may be required. 

Where the inflammation is excessive, it will *be requisite to 
apply four or five leeches at a little distance from the chancre, 
and promote the bleeding by warm fomentations. A saturated 
solution of the watery extract of opium should be applied warm 
to the part, and be renewed three or four times during the day. 
The solution should be strained through fine linen. Cold dress- 
ings rarely suit. 

If phymosis or paraphymosis take place, the surgeon should 
lose no time in removing them. The same mode of operating 
is to be pursued as in ordinary cases, practical directions for 
which have already been considered. Mr. Acton mentions an 
accident which he once witnessed at an operation performed by 
a hospital surgeon. The latter designed to slit up the prepuce 
for the relief of phymosis. The director was introduced into 
the urethra, instead of passing between the prepuce and glans. 
The bistoury followed the director ; and the urethra, as well as 
the prepuce, was slit up to the extent of an inch. 

After the operation for the relief of phymosis or paraphymosis 
is performed, the opium and water dressing must be applied. 
Sometimes a profuse hemorrhage takes place in consequence 
of partial destruction of some blood-vessel by gangrene. Dry 
lint or powdered alum will generally control it. 



CHAPTER XXII. 

PHAGEDENIC CHANCRE. 

Phagedenic • chancre is the result of acute inflammation 
unsuccessfully treated. Inflammatory chancre is liable to 
progress to a state of gangrene and sloughing, and the pha- 
gedenic sore is the ultimate stage or point to which inflam- 
mation can extend. 

Practically, the distinguishing line between gangrene and 
phagedena is not very important ; and yet there is a differ- 
ence between the two, both in regard to the condition of the 
patient's system at the time, and as respects the state of the 
parts involved in the local disease. Abernethy employed the 
term phagedcena to express every form of destructive sore, 
whether owing to ulceration or sloughing. Acton's distinction 
between phagedena and gangrene is clear and brief. It is this : 
Some local irritating agent is the cause of inflammatory or gan- 
grenous chancre, whereas a peculiar state of the constitution 
exists in a patient suffering from phagedena. In gangrene 
the general health is not impaired ; in phagedena it is. In 
gangrene there is death of the parts ; in phagedena a sort of 
liquefaction takes place, and a melting down of the adjacent 
structures, which have been previously destroyed. Dr. Egan, 
speaking of phagedenic, primary ulcer, confines his description 
to that class of ulcer which commences as a phagedenic sore, 
although he does not ignore the fact that many others may 
assume this character from neglect, from local irritation, or 
from the internal use of even small quantities of mercury. He 
mentions one instance, under his care, which became phagede- 
nic from the administration of ten grains of blue pill. 

The phagedenic chancre always denotes a depraved condition 
of the animal economy. The patient looks haggard, has what 
we call a broken-down constitution, induced perhaps by a 

(240) 



PHAGEDENIC CHANCRE. 241 

variety of causes, such as intemperate habits, excessive debauch- 
ery, and other irregularities connected with a life of dissipation, 
confinement in the wards of a badly-ventilated hospital, or living 
in any unwholesome situation, and by any other adverse condi- 
tions, which the medical attendant will do well always to inquire 
into. Sailors who have been engaged in long service, and who 
consequently have been exposed to the hard vicissitudes of the 
sea, and individuals of a scrofulous and lymphatic diathesis and 
flabby muscular fibre, are also to be included in the list of those 
in whom the phagedenic chancre is apt to appear. Now and 
then we meet with- patients who are not slow to attribute this 
form of their disease to the improper treatment which they 
fancy they have received from the attending surgeon or physi- 
cian ; and thus the skill of the practitioner may be unjustly 
impugned. Not long since, I was called in consultation by a 
young physician, and was witness to the state of things here 
spoken of. The patient, however, upon being confronted and 
closely questioned, admitted that he had led a profligate life 
for years ; and he was very plainly told that his condition was 
chargeable in every particular to his vile habits, and not to any 
improper medical treatment. The young physician retained 
the daily charge of the case, and heard no more insinuations 
as to malpractice. 

The progress of this chancre, if neglected, is very rapid ; the 
constitutional symptoms, to which it gives rise, are of a more 
serious type than those attending any other primary sore ; and 
there is no accident, of a syphilitic origin, more worthy of the 
study of the practitioner than this. Let me be permitted to 
say, that he should make himself and keep himself familiar with 
its nature, and with the best mode of managing it ; for he is 
liable to be called upon in circumstances requiring decision and 
immediate action. True he may not be summoned to amputate 
a limb ; but his cool and collected self-possession, his enlightened 
judgment, and his practical services may be wanted in a crisis 
of scarcely less magnitude ; and a judicious, impromptu pro- 
cedure may not only save an important part of the human frame 
from destruction, but even rescue the individual from impending 
death. Sometimes, when the phagedena seizes upon the pre- 
puce, the whole of this membrane will be swept away in thirty 
hours ; and where the glans is attacked, the destructive action 
21 



242 GONORRHCEA AND SYPHILIS. 

advances with nearly equal rapidity, involving all the structures 
of the organ, which in two or three days becomes a revolting 
mass of putridity. 

The phagedenic chancre is seldom followed by secondary 
symptoms. In this lesion, the condition of the parts, so far as 
relates to contagion, is precisely what the surgeon secures when 
he destroys the recent indurated chancre by the application of 
potassa fusa, or other escharotics. In both cases, the phagedenic 
action cuts off the absorbent vessels, and the poison, which is 
still confined to its original locality, is also destroyed and cast off 
with the detritus of the sore. Thus the patient escapes consti- 
tutional infection. It is not absolutely certain, however, that 
in all cases no secondary accidents will supervene upon the 
phagedenic chancre. The virus may have been taken up by 
venous absorption, or have crept into the system through the 
lymphatics, before they were obliterated by the sloughing 
process, but the danger is very trifling ; and those who advocate 
the old method of mercurial treatment, consider it good practice 
to spare the patient, at this juncture, the debilitating effects of 
such a course. 

Teeatment. — In all cases, the patient should be required to 
keep his bed, and, if possible, he should have the benefit of a 
large, well-ventilated apartment. He will need a generous diet 
and a good allowance of sherry wine. A decoction of hops 
with wine in it makes a good tonic beverage, especially for 
those who, while in health, have been accustomed to stimulating 
libations. 

What has already been said in regard to the advantages to be 
derived from the warm bath and aperient medicines, is, in the 
main, applicable here. Although the evil we are now consider- 
ing is due to some specific cause, it is to be treated without 
reference to this origin. The existing condition of the patient, 
both as relates to the local and constitutional symptoms, should 
engross the attention of the medical attendant exclusively, and 
the case should, in all particulars, be conducted as a simple 
phagedena, uncomplicated with syphilis ; for as soon as the un- 
favorable symptoms are subjugated, and the chancre assumes the 
character of a simple, healthy sore, which it can generally be 
made to do, it will heal without difficulty, and the patient will 
in all respects make a good recovery. 



PHAGEDENIC CHANCRE. 243 

A majority of patients suffer extremely from constitutional 
irritation at this crisis, and the free employment of opium in 
some form will be imperiously demanded. The solid pill is, 
perhaps, to be preferred. In regard to the aggregate quantity 
per diem, the amount must be proportioned to the condition of 
the patient, and his susceptibility to the specific action of the 
drug. It will be safe to begin at early bedtime with a pill con- 
taining two grains. Let this be repeated every three hours, or 
thereabouts, until the desired effects are realized. Two of these 
pills will usually be sufficient to procure quiet sleep, and on the 
following day the patient will be likely to find himself in a com- 
fortable state. It is, however, sometimes necessary to give six, 
eight, or ten grains of opium in the course of twenty-four hours. 
If it should impair the appetite, or otherwise disturb the func- 
tions of the digestive organs, a little wine in connection with it 
will, in a great measure, prevent any inconvenience. The wine 
will not only tend to correct any unpleasant effects of the opium, 
but will act in unison with it in bringing about an amendment 
of the patient's general condition. As soon as the morbid irri- 
tability is quieted, the amount of opium should be very much 
diminished. 

The chlorate of potash is a useful article to be employed in 
arresting any phagedenic tendency, and inducing healthy action 
in the ulcerating surfa.ce. Internally, it may be given, dissolved 
in barley-water, to the amount of a drachm during the day. As 
a topical application to the ulcer, the annexed formula can be 
advantageously employed : — 

R. Potassae Chloratis, . 5 iv. 

Aquae Destillatae, § viij. M. 

To be constantly applied, as a dressing, by means of lint.* 

Potassio-Tartrate op Iron. — I must again present the 
claims of this salt. As a therapeutic agent both constitu- 
tional and local, in the condition of things before us, it is often 
to be preferred to the chlorate of potash, and, indeed, to every 
other article in the materia medica. It was 'first recommended, 
some fifteen years ago, by Ricord, who employed it " to iron up 

* Vide Guy's Hospital Reports, vol. vii., p. 331. 



244 GONORRHOEA AND SYPHILIS. 

the blood." Where the patient is in a feeble, anaemic state, re- 
quiring a tonic course of treatment, this ferruginous preparation 
is entitled to the highest confidence. At the onset of phagede- 
nic action it may be resorted to with every prospect of advan- 
tage. The opiates, which may be appropriate for a time to 
allay the morbid sensibilities of the patient, will constitute no 
barrier to the free administration of the iron. While these 
medicines are in constant use, an occasional small dose of cas- 
tor-oil will be required to preserve the bowels in a suitable 
state. 

For phagedenic ulcers, in whatever tissue situated, and at 
whatever period of the syphilitic disease, the iron will display 
an efficiency of power not inherent in any other remedial agent. 
I have employed it almost daily for about eight years, with re- 
sults every way satisfactory, for the improvement of the consti- 
tution of individuals laboring under various forms of venereal 
affections. It is especially adapted to those cases in which the 
exhibition of mercurials would be prejudicial. I can scarcely 
overrate its value. In phagedena all medical men agree that 
inercurial agents should be excluded, and all who have fairly 
tested the potassio-tartrate of iron, I know, will corroborate any 
expressions of praise I might choose to employ. I am sure that 
this article has not acquired that notoriety and favor to which it 
is entitled. Administered internally as .a tonic, it can be relied 
upon as particularly suited to a numerous class of patients suf- 
fering not only from phagedena, or sloughing ulcers, but from 
every other variety of venereal ulceration, especially if the con- 
stitutional integrity be much impaired. In saying thus much, I 
have to observe that I have no experience with it in indurated 
chancre, or strictly inflammatory chancre.* The iron may be 

* Mr. Behrend, of Liverpool, extols the use of this remedy in every case 
of primary syphilis. He was first induced to try it, in a case of very large and 
obstinate chancrous sore, in 1854. It had existed three months, and had been 
treated with various local applications without benefit. The patient had other- 
wise been under good medical care, but had wasted away from pain, loss of 
appetite, and loss of sleep. The sore was situated partly on the penis and 
partly on the scrotum. The patient commenced the use of the iron, and in 
one month was cured Mr. Behrend, holding the opinion that the virus of a 
phagedenic chancre is identical with that of every other form (the phagedena 
being, in his opinion, attributable to special circumstances, and, as it were, a 
modification superadded to the original disease), determined to treat every case 



PHAGEDENIC CHANCRE. 245 

continued from the moment any phagedenic symptoms present 
themselves until the chancre is healed. The best mode for its 
exhibition has already been considered. A saturated solution 
makes a valuable application for the phagedenic sore. After 
the strong solution has been applied for two or three days, the 
aspect of the chancre is transformed into that of a simple 
healthy sore, exhibiting abundant granulations, and showing 
no further disposition to spread. The solution should then be 
much diluted. A drachm of the salt to eight or ten ounces of 
water will furnish a lotion of suitable strength, and it can be 
relied upon in maintaining a recuperative influence on the local 
disease. Sometimes there is excessive irritability about the sore, 
as well as about the patient, and it will not at first bear stimula- 
tion. In such cases, the opiate lotion must be employed for a 
short period. At a later day — that is, as soon as the patient 
has been brought under the constitutional effect of the opium and 
iron — the local irritation will be essentially ameliorated, and a 
different management of the lesion must be adopted. The 
ferruginous solution must be taken in the manner already 
advised. 

Although my experience amply justifies the encomium I have 
bestowed on the potassio-tartrate of iron as a remedy in phage- 
dena, there are cases in which the concentrated nitric acid is 
to be preferred as a local remedy. I refer to those in which 
sloughing phagedcena is the predominant complication of the 
chancre. If the sloughing process advance with rapidity, there 
is, in fact, acute gangrenous inflammation, and the acid should 
be applied. Let a bit of soft sponge be secured to a piece of 
whalebone, and be well charged with the acid, but not so as to 
drip. Pass it quickly over the phagedenic surface. A bowl of 
warm water should be at hand, and the superfluous acid be 
instantly washed off. A warm cracker poultice, to which a 
large quantity of the solution of the watery extract of opium 
should be added, must then be laid upon the part ; or, if a poul- 
tice cannot be employed conveniently on account of the locality 

of primary syphilis in precisely the same way ; and he states that the accumu- 
lative experience of each case has confirmed him in the correctness of his views, 
and has given him entire confidence in the powers of the potassio-tartrate of 
iron to cure every kind of primary sore. — Vide London Lancet, 1856, pp. 
534, 673. 

21* 



246 GONORRHOEA AND SYPHILIS. 

of the chancre, the opiate solution can be used alone. The 
patient will also require a large dose of opium or morphia at 
this time. In a day or two the slough will be cast off, in some 
places at least, and a healthy surface here and there be brought 
to view. Although the acid may not again be needed on so 
large a surface as at first, still the surgeon may expect its par- 
tial application will be required every three or four days, until 
the whole surface presents a granulating appearance. The 
presence of the acid, as here recommended, gives intense agony 
for the time being, and, in some instances, induces faintness for 
several minutes. To prevent these unpleasant effects, it may 
be well to put the patient under the influence of ether. 

After the chancre has acquired a healthy, florid aspect, and 
inflammation and sloughing are no longer to be dreaded, it will 
still be necessary to employ the nitric acid, but in a different 
manner from that advised above. For continued use, the fol- 
lowing solution will be found to answer a good purpose': — 

ft. Acidi Nitrici, 5 ss. 

Aquae Fontanse, § xvj. M. 

The chancre is to be kept covered with linen rag, wet with 
the lotion. Soft linen rag is on some accounts better than lint. 
The latter is apt to get entangled with the uneven surface of 
the chancre, which is now very tender, and the granulations are 
easily torn so as to bleed. In a few days they acquire more 
firmness and consistency under the influence of the acid lotion, 
and then the surface can bear less delicate manipulation with- 
out injury. While this topical dressing is employed the patient 
experiences a sensation of warmth and a slight itching in the 
part, but no pain or smarting worth speaking of. I have made 
trial of nearly all the local remedies in vogue for such lesions, 
and know of none that keep the surface so clean and nice as 
this ; and it generally exerts a salutary influence in bringing 
forward healthy granulations. Should the chancre yield an 
offensive, purulent, or sanious discharge, a solution of the 
French chloride of soda will correct this condition. The fol- 
lowing strength will be tolerated without complaint; — 

ft. Solutionis Sodse Chloridi, <$ ss. 

Aquae Fontanse, § v. M. 



PHAGEDENIC CHANCRE. 247 

The -chlorate of potash, as a lotion, may be employed as 
an excellent detergent and antiseptic in chronic foetid, sup- 
purating ulcers, wherever situated. It proves very serviceable, 
also, in ulcerated surfaces exhibiting a tendency to sloughing. 
The formula prescribed at the Royal Free Hospital of Lon- 
don is composed of half an ounce of the chlorate of potash 
to a pint of water, with forty drops of strong hydrochloric acid. 
It is stimulating in its action also, and converts a foul ulcer into 
a healthy, granulating sore. The sore should be kept constantly 
wet with the solution by means of surgeon's lint saturated with 
it, and covered with thin sheet gutta-percha. As soon as the 
recuperative process is well established, the strength of the 
solution should be reduced. 



Carbonate of Ammonia. — This is a remedy which is capa- 
ble of fulfilling an important indication in the treatment of 
phagedenic chancre ; and, before taking leave of this subject, 
I cannot forbear commending it to the attention of the practi- 
tioner. In its mode of operation on the dilapidated economy, in 
the circumstances now supposed, it differs materially from the 
other articles of the class to which it belongs. The immediate 
impression upon the stomach, and the genial thrill which it 
sends throughout the system, are always grateful to the patient ; 
and the stimulus which it imparts to the vascular and dermoid 
tissues approaches nearer to that of normal action than can be 
exerted by any other remedial agent. It may, therefore, be 
given in almost any emergency, even when other stimulants 
and incitants would be inadmissible on account of any inflam- 
matory diathesis or action that may exist. Its use is compati- 
ble with that of opium, or of the favorite ferruginous prepara- 
tion of Ricord. It is especially suited to that class of patients 
whose constitutions have been injured by long indulgence in 
the use of intoxicating drinks, late hours, and all manner of 
debaucheries, and who may be suffering from the additional 
weight of the particular affection under consideration. In 
these circumstances, I have been accustomed to prescribe the 
ammonia for several years, as in the annexed formula : — 



248 GONORRHOEA AND SYPHILIS. 

R. Ammonia? Carbonatis, 5 j. 

Pulveris Acacia?, 

" Sacchari, aa, 5ij- 

Aquae Fontanse, . . § iv. 

Cinnamomi Olei, gtt. j. M. 

Dose. — A table-spoonful every three hours in half a gill of cold water. 

Although I have commented favorably upon several articles 
in connection with the treatment of phagedenic chancre, it is 
hardly to be supposed that there will ever be occasion to mar- 
shal all these forces into the field of action at the same time. 
They would thus produce confusion r not benefit. In reference 
to the* ammonia, I would add that, for female subjects especially, 
it will be found an excellent substitute for alcoholic stimulants. 

Thus far I have been nearly silent in regard to the employ- 
ment of mercury in this destructive form of ulceration. If any 
medical practitioner is so partial to it as to recommend it in 
these circumstances, he will probably not only find it valueless, 
but decidedly hurtful. Let us suppose the young surgeon at 
the bedside of a miserable human being, male or female, whose 
constitution is well-nigh in ruins from scanty food, continual 
dram-drinking, the pestiferous fog of theatres and brothels, ir~ 
regular hours, and various other predisposing causes connected 
with a dissolute life, and who is now the victim of a foul, angry- 
looking, eroding ulcer — the mere dregs of syphilis — upon 
some portion of the genitals. In such cases the patient always 
has a quick, feeble pulse, indicative of great prostration and 
waning of the bodily powers. Even if the morbid action have 
existed but a short time, it is surprising how rapidly the patient 
fails. Let the surgeon now inquire what specific good can 
accrue from the presence of any mercurial preparation in such 
a shattered frame. If he should administer it, it will be found 
not only barren of all good results, but absolutely baneful both 
as regards the local disease and the general system. Even in 
small quantities, and where it does not induce tumefaction or 
redness of the gums, it may play a mischievous part by increas- 
ing the tendency to slough, and its injurious effects by no means 
admit of easy reparation. I am confident I have seen examples 
illustrative of these remarks. I will cite one instance. 



PHAGEDENIC CHANCRE. 249 

Case. May ISlh. — I was requested to give advice, from 
time to time, in the management of a phagedenic chancre, of 
which a young practitioner of the city had charge. It hap- 
pened to be the first effort of his practical skill in the syphilitic 
department. The patient was a wandering Englishman, thirty 
years of age, unmarried, of nervous temperament, a hard 
drinker, a great smoker, a frequenter of brothels, and occupy- 
ing as his lodging-place, while sick, a small, filthy apartment in 
a house devoted to licentiousness. At the time of my first visit 
he was lying on a bed of rags, and was covered and surrounded 
by all the paraphernalia of filth and moral degradation. He 
had a prostitute for his nurse. 

It appeared that, a few days after exposure, a chancre came 
upon the glans, near the frgenum. The patient consulted 
this young physician, who attempted the destruction of the 
sore by the abortive treatment. Nitrate of silver was applied 
for several days in succession, the patient being abroad mean- 
time in the streets, regardless of any advice to the contrary. 
Erysipelatous inflammation ensued, and progressed with its 
wonted activity in such cases, until it resulted in phagedena. 
It is not easy to convey a true idea of the unique appearance 
of things on this occasion. The glans was swollen ; a para- 
phymosis tightly girded the parts, and the prepuce and integu- 
ment farther back were much tumefied and oedematous. The 
serous effusion had infiltrated the meshes of the interstitial cel- 
lular membrane in a somewhat interrupted manner, so as to be 
confined in small elongated sacs, which took a spiral direction 
part of the way around the swollen organ ; and thus there were 
three or four bands producing a twisting and partial strangula- 
tion. The virile member, as a whole, bore no small resem- 
blance to a short screw auger. The patient was lying on his 
back. The primary chancre was close to the fraenum ; but it 
was now nearly obliterated, being merged in the phagedenic 
mass. The pulse was quick, small, and hard ; the tongue 
white ; the skin dry and hard ; there was thirst ; severe pain in 
the glans and along the whole penis ; constant nervousness, and 
involuntary muscular agitation, like that witnessed in the early 
stage of delirium tremens. For the two previous nights he got 
but little sleep. He had taken submuriate of mercury pills 
for eight or nine days, but no specific effect had been produced 
in the mouth. 



250 GONORRHOEA AND SYPHILIS. 

It was agreed that the pills should now be laid aside, and 
that opium should be given in two-grain doses, every three 
hours, until the patient should obtain sleep ; and that he be 
kept under the influence of this drug so long as any constitu- 
tional irritability remained. The prepuce was scarified at 
several points, and the parts dressed with warm solution of the 
extract of opium. The paraphymosis was at once relieved by 
the disgorgement from the prepuce, and the swelling and pain 
in the strangulated glans subsided in a few hours. The man 
was put upon the free use of carbonate of ammonia julep, 
according to the formula just given, together with wine and 
quinine. The chancre was touched with the concentrated 
nitric acid several times ; and, for an ordinary dressing, the 
opiate solution was prescribed for a short time ; then the chlo- 
ride of soda ; and, at a later period, the dilute nitric acid. The 
pulse and tongue got nearly right in about one week from the 
day I first saw the case. There was loss of a considerable por- 
tion from the right side of the glans and the corresponding 
part of the corpus cavern osum. The fraenum was destroyed, 
and also a portion of the prepuce. At one time the organ had 
an unpromising aspect. From the walls of the chasm occa- 
sioned by the sloughing, granulations sprung up in healthy 
style ; the mutilated glans was soon brought in apposition with 
the cavernous body, to which it united very cleverly. The cure 
ended with a somewhat odd deformity, although the patient 
was very well satisfied. He left his quarters suddenly one 
morning for parts unknown, allowing his young surgical attend- 
ant to realize his fee in the practical knowledge he had given 
him an opportunity to acquire. 

Occasionally the surgeon is consulted by a man who has been 
exposed, and whose condition is something like this : the penis 
is swollen and painful, and exquisitely tender on pressure at 
some particular spot along the corona glandis. The prepuce is 
also inflamed, and of a deep livid color. It is in a state of phy- 
mosis over the glans. There is a thin, bloody, and highly offen- 
sive discharge from the preputial orifice, which is much con- 
tracted. As no other lesion of these parts is at all likely to 
yield such a peculiar secretion, it may be considered, in connec- 
tion with the concomitant phenomena, .as furnishing almost 
unequivocal evidence that there is a concealed, phagedenic, 



PHAGEDENIC CHANCRE. 251 

sloughing sore on the corona or on the mucous surface of the 
prepuce. In these circumstances, the surgeon should, without 
delay, slit up the prepuce along the dorsum of the glans, so as 
to bring the chancre into view, and then apply the strong fer- 
ruginous solution or the undiluted nitric acid. 

Phagedenic chancres on the penis not unfrequently destroy 
the parts to such an extent that amputation becomes necessary 
as a final measure. It was said by Dr. Physick, of Philadel- 
phia, that he had amputated a hatful of such specimens. 

In addition to the chancres already mentioned, there are 
other varieties of primary syphilitic sores, which have been 
designated by the names of phagedenic gangrenous chancre, the 
pultaceous diphtheritic chancre, the serpiginous, or creeping, 
chancre, etc. In all these varieties the abnormal process is of 
similar character, and requires to be dealt with in a manner 
analogous to that which is found most beneficial in the form of 
chancre which has just been considered. 

In all cases of phagedena the patient will require a generous 
diet. Eggs, milk, broths, and, as the digestive apparatus 
acquires ability, mutton-chop and beef-steak will constitute an 
appropriate bill of fare. 

Chancres in women are wont to assume a more unfavorable 
disposition than in men. These lesions may exist on the nym- 
phe, or on the inner surface of the labia, for a long period, and 
yet the patient be unsuspicious of their nature. In fact, they 
give little or no pain or irritation until they acquire a large 
size, and the woman is hardly conscious of their presence. 
The first symptom that attracts her attention is a sensation of 
smarting and prickling, occasioned by the act of micturition. 
If, however, the chancres are allowed to have their own way, 
unchecked, they sometimes penetrate into the cellular tissue, 
and degenerate into sloughing ulcers, and total destruction of 
the parts is the result. Females in whom this description of 
ulcer is found are usually of a most abandoned character, of 
dissolute habits, and broken-down constitution. The sore gen- 
erally commences as an abrasion, or perhaps as an angry-look- 
ing pimple, on the labia, and is soon encircled by an unhealthy, 
lurid areola, and from inattention, as well as in consequence of 
a vitiated condition of the system, it does not take on a normal 
granulating action, but shows a tendency to spread in every 



252 GONORRHOEA AND SYPHILIS. 

direction, and yields a thin, sanious, foetid discharge, mixed 
with debris. At a later period, dark-colored sloughs begin to 
form in quick succession, and become more and more extensive, 
until the vagina and the perineal and anal regions are involved. 
Sometimes the entire lower opening of the pelvis is deprived of 
the soft parts in consequence of the sloughing process. Exces- 
sive local pain at length becomes a prominent and abiding symp- 
tom ; there is high irritation or inflammatory fever, which ulti- 
mately assumes a typhoid character, with more or less delirium ; 
the pulse is rapid, and indicative of great constitutional debil- 
ity ; the appetite fails ; all the vital functions are deranged ; 
exhausting hemorrhages take place from different points of the 
immense ulcerated surface, and the frail victim dies from the 
combined effects of bad liquor, debauchery, and syphilis. For- 
tunately this form of venereal affection is rarely met with. 
Now and then a female, who has long suffered from it, is taken 
from one of the terrible dens of our large cities, and placed in 
some charitable institution. But, in consequence of delay, her 
chances of cure are exceedingly small. If the case receive 
proper medical attention before the sloughing process has 
reached an advanced stage, it is not usually difficult to cure 
the patient. The concentrated nitric acid, a saturated solution 
of the watery extract of opium, a weak solution of the chloride 
of soda, Peruvian balsam, and warm fomentations, comprise the 
most reliable and efficient local therapeutic means ; and the 
constitutional treatment should consist of tonics, large doses of 
opium, occasional laxatives, liberal diet, wine, porter, and a 
wholesome atmosphere. In the Magdalen wards of some of the 
London hospitals this disease has long been known as the "Swan 
Alley sore." Swan Alley is the name given to a place which 
no longer exists, having been swept away to make room for 
better structures and better purposes. The prostitutes, who 
formerly tenanted these lower regions, lived in an immense 
underground vault for weeks and months together, without see- 
ing the light of day, or inhaling a breath of salubrious air. 
They had unlimited intercourse with foreign sailors, many of 
whom were Lascars and colored men. They were of slender 
frame, in most instances, and had fair, light complexions, light 
hair, and were generally from fifteen to twenty-five years of 
age. They were decoyed from the country by Jews, who kept 






PHAGEDENIC CHANCRE. 253 

these subterranean abodes, and were systematically on the look- 
out in the neighboring thoroughfares. They were scantily fed, 
and had an abundance of gin. These primary, phagedenic, 
sloughing ulcers do not furnish contagious matter, nor do the 
females who recover from them ever have secondary constitu- 
tional symptoms. So said the late Mr. Travers, who furnished 
a graphic description of them, a few years since, in the London 
Medico-chirurgical Review. 
22 



CHAPTER XXm. 
BUBO. 

Hunter regarded the syphilitic bubo as a primary accident. 
There is no instance recorded in which this lesion has ever had 
its origin in a secondary venereal sore ; nor is it, on the con- 
trary, with a few rare exceptions, ever developed as a specific 
affection, unless a chancre has preexisted. A few well-authen- 
ticated cases of bubon d'emblee, or primitive bubo, have been 
met with.* Ricord mentions eight ; Mr. Erichsen has seen one ; 
Mr. Lane a few, and so on. Mr. Parker has never seen one 
primitive bubo, which has been tested by inoculation, and thus 
proved to be of a syphilitic character ; but he is disposed to 
admit that such cases have been seen and verified by surgeons 
of experience, and who are worthy of credit. 

I think it is not far from the truth to consider a virulent bubo 
as holding an intermediate position between primary and sec- 
ondary syphilis. It has been not inaptly called the half-way 
house between the two stages of the disease. 

The student will seek in vain for entire uniformity of opin- 
ion among the best authorities in regard to the frequency or 
certainty with which bubo attends or supervenes upon a chan- 
cre. Some maintain that chancre always begets a bubo ; others 
assure us that enlargement of the ganglia of the inguinal region 
does not, in all instances, take place ; and that the secondary 
symptoms may be developed, notwithstanding the fact that 
these glands remain intact. Buboes usually occur on the same 
side. that is the seat of chancre. If the latter be situated on 
the frsenum, a bubo may be developed in either groin, or in 
both right and left. Buboes that arise in consequence of indu. 

* M. Ricord, it is said, now denies the existence of the primitive virulent 
bubo, — "bubon d'emblee" produced by the absorption of a special virus, and 
where there has been no suspicious antecedent, — chancre, excoriation, or sore. 

(254) 



BUBO. 255 

rated chancre, rarely suppurate, being subject to the same law 
of morbid action that governs the chancre. Such buboes are 
regarded by some writers as nothing more nor less than chan- 
cres seated in these glandular bodies. They are also denomi- 
nated indurated, indolent, constitutional buboes, and, as they 
never suppurate specifically, some surgeons consider that no 
local treatment is ever serviceable in their removal. 

The period at which a bubo appears, after the occurrence of 
chancre, is not. limited to any definite time, although it gener- 
ally begins to show itself about the second week after the for- 
mation of the parent sore. In the male subject, the bubo is 
most frequent when the antecedent chancre is situated on some 
portion of the prepuce, or on the fraenum ; and in the female, 
when the chancre forms at the meatus urethrcE, or near the 
anterior verge of the anus. If the patient has a good consti- 
tution, and is seen, sufficiently early for the successful applica- 
tion of the abortive treatment, a bubo will not supervene. 
Surgeons formerly had an idea that if the chancre was de- 
stroyed at an early period, the virus might be driven into the 
system, and that a bubo would consequently be more likely to 
form. 

The true syphilitic bubo is very indolent in its progress, 
remaining nearly stationary for several weeks, causing but 
little pain or other inconvenience ; but the mere fact of its 
existence is of no trifling significance. It shows that the sys- 
tem is impregnated with the specific virus, which has found its 
way into the channels of intercommunication, and, through the 
medium of the blood and other fluids, has poisoned the whole 
animal economy. The bubo of other varieties of chancre is 
more acute, more painful, and generally involves the glands of 
only one side. Buboes are sometimes produced, not by absorp- 
tion, but by irritation, in scrofulous and other unhealthy sub- 
jects. These cases are not difficult to be distinguished. Sim- 
ple inflammation is set up, chiefly in the deep-seated glands, 
which do not become the recipients of the venereal element 
through the medium of the lymphatic vessels. 

Sometimes there is a deviation in the locality of inguinal 
bubo. It may be seated farther down the thigh, or farther 
towards the pubes, or close in front of Poupart's ligament. 
I once met with the latter deviation in a young man. In this 



256 GONORRHOEA AND SYPHILIS. 

case the swelling attained a large size, was round, and pushed 
forward the cutaneous and cellular membranes, as if a small 
flat onion were underneath. The unusual position of the swell- 
ing is due, of course, to the abnormal locality of the glands, 
and it is well to bear in mind the possibility of this anatomical 
peculiarity, otherwise some embarrassment or error might occur 
in our diagnosis. 

The virulent matter of the true syphilitic bubo retains its 
contagious property so long as it remains in the ganglion ; that 
is, it is inoculable. 

In regard to the frequency of inflammation and suppuration, 
the general rule is this : if the bubo be the result of a non- 
indurated chancre, its tendency is to advance to suppuration; 
whereas, the contrary is the fact if the original chancre be of 
the indurated variety. 

It is a matter of great consequence that we should be correct 
in our diagnosis of the kind of bubo we meet with, because 
important therapeutic indications are founded on the opinion 
we form of the character of the swelling. Let me illustrate by 
presenting the following 

Case. — A short time since, a young man, whom I had for- 
merly attended for constitutional syphilis, called upon me one 
morning, in great distress on account of a bubo in the right 
groin. He first noticed a slight tenderness and swelling four 
weeks before he made this morning call. He had already con- 
sulted a young medical friend of his in reference to his case, 
which was pronounced to be syphilitic ; and among other things 
that were done by the advice of this young medical gentleman, 
a blister, about four inches square, had been applied several 
times to the groin, in the hope of dispersing the swelling. The 
patient, being connected with an extensive mercantile house, 
and having, on a former occasion, been detained from business 
for several months, had great reluctance to incur a second sus- 
pension from duty, especially for such a reason, and conse- 
quently continued, as usual, at his employment, but suffering 
constant pain, which increased from day to day with the growth 
of the bubo, this being now exceedingly hard and voluminous. 
It occupied nearly the whole of the inguinal fossa, and all the 
lymphatic glands situated in this region seemed to be involved 



BUBO. 257 

in the swelling. The mass was perfectly immovable, and in all 
its features, taken in connection with the history of the patient, 
it appeared to exhibit the character of a scrofulous bubo, as 
generally understood and described. The patient had a coated 
tongue, quick pulse, loss of appetite, and loss of strength and 
flesh ; he relied on opium for sleep by night ; the bowels were 
costive, and there was intense mental distress, amounting 
almost to insanity. He was truly an object for pity. He pre- 
tended to consider the bubo as the relic of his former venereal 
trouble. I assured him that this was not the fact, and inquired 
if he had not been recently exposed to infection anew. He 
gave a negative reply, in a prompt manner, as. if to repel the 
inquiry with indignation ; but the style of his denial betrayed 
guilt. I examined the penis, and it did not take long to dis- 
cover the cause of the bubo, as I had occasionally met with 
other similar instances. A vesicular eruption, with a delicate, 
pinkish color and slight oedema, occupied the entire border of 
the prepuce. Some of the vesicles ha*d discharged their con- 
tents several days previously, and a thin, flat scale had formed 
upon their summit ; other vesicles had been broken more 
recently, and were without any covering. They appeared like 
minute open cups, barely visible to the naked eye, and yielded 
a slight limpid secretion. There were other vesicles, still 
younger, that had not ruptured the epiderma. 

After I had carefully examined the organ, the patient asked 
what I thought of it. I told him that I strongly suspected that 
he had lately had intercourse with an impure female. I would, 
however, hear any explanation he had to offer relative to the 
diseased condition of the prepuce, which I regarded, in part, as 
the cause of the bubo. He acknowledged that he had been on 
intimate terms with a woman whose husband was in California. 

The eruption in this case was herpes prceputialis . It had 
existed about two months ; some of the time being quite 
troublesome, at other times nearly well, according to the habits 
of the patient. Instances of this vesicular affection, produced 
by non-venereal vaginal discharges, are occasionally met with. 
The herpetic eruption, when developed in highly sensitive sub- 
jects, will sometimes give rise to tenderness and pain in the 
inguinal glands. In the present instance, the patient had been 
told that he had a chancre on the prepuce, although this was 
22* 



258 GONORRHCEA AND SYPHILIS. 

not the fact ; and he was at once, and very naturally, appre- 
hensive of a syphilitic bubo. He was on the alert for abnormal 
sensations and developments in the groin. His fingers were 
almost every moment thrust into his trqwsers and pressing upon 
the glands, and thus their tenderness was increased. At length 
his fears, confirmed by the unfortunate diagnosis of his young 
medical friend in regard to the preputial affection, prevailed in 
the case. 

There are instances in which it is difficult to distinguish a 
true chancre in its early vesicular stage, if it appear as a ves- 
icle, as it sometimes does, from herpes of the prepuce. In 
such cases, if we wait until ulceration commences, the charac- 
ter of the disease will become sufficiently distinct. The young 
physician, who preceded me in charge of the present case, 
decided at first that the herpetic eruption of the prepuce was 
a chancre. This was by no means a singular or uncommon 
mistake, and yet it was a very serious one, and led to an 
equally great one in the immediate treatment, both local and 
constitutional. The slight trouble in the inguinal region was 
also misinterpreted. It was regarded as the result of absorption 
of the venereal virus. I am happy to say here that the young 
physician, to whom I have referred, had an opportunity to 
study out the case, and ultimately arrived, sua sponte, at the 
just conclusion that there was no syphilitic element in it. In 
further explanation of the case, which is an interesting one to 
dwell upon, I have to remark, that the repeated application of 
the blister, and the active business habits which were main- 
tained with such reckless pertinacity, under so many disadvan- 
tages, soon aggravated the inguinal difficulties of this young 
man, who possessed a scrofulous diathesis. For several weeks 
he would listen to no advice as to the importance of keeping 
quiet, and the consequence was that he continued to lose 
ground, until he broke completely down, charging his failure 
to lack of medical skill. The bubo at length suppurated. The 
constitutional symptoms were severe, and the patient continued 
to suffer more and more, until his condition became alarming. 
When the bubo on the right side had nearly healed, a similar 
one appeared in the opposite groin, and pursued a like tardy, 
and chronic course. For nearly ten months a general cachexy 
seemed to pervade the economy, and extreme emaciation and 



BUBO. 259 

debility ensued ; but, fortunately for the poor fellow, he ulti- 
mately recovered sufficiently to return to his home, which was 
far distant from New England. I have stated that this patient 
had, on a former occasion, suffered severely from constitutional 
syphilis, and he had not wholly recovered from its ravages. In 
designating the particular variety of buboes which he had, how- 
ever, I know not a more appropriate epithet to employ than the 
one I have chosen ; for the inguinal swellings, which the patient 
had, and their entire history, correspond in character with the 
scrofulous bubo so graphically depicted by Hunter. The pa- 
tient had no sore throat, no disease of the skin, bones, or peri- 
osteum, during the period embraced in the foregoing account. 
Nevertheless, if we go back a step farther, and inquire whence 
this scrofulous diathesis was derived, we need not hesitate to 
admit that the previous constitutional syphilis contributed a 
large share to its production, using the term scrofula in the 
sense adopted by Hunter. Perhaps, in more modern phraseol- 
ogy, sympathetic bubo would sound better. 

Treatment of Buboes. — To the patient it is a matter of 
great importance that the bubo should be dissipated as soon 
as possible, without being allowed to suppurate. But what de- 
gree of efficacy will be exerted by any remedies we can em- 
ploy, with a view to control the tendency of the diseased action, 
is uncertain. Yidal says that a bubo which should suppurate 
will suppurate, no matter what we do ; and the bubo that should 
disappear by resolution will thus disappear, in spite of the ordi- 
nary suppuratives, except they be too violently used ; and yet 
Vidal would not dispense with treatment. 

In private practice, one of the greatest obstacles to success 
in our endeavors to annihilate a bubo, is the inability or re- 
luctance of the patient to observe that repose which is so es- 
sential. He should be confined to his bed or couch. Here is 
his surest place of safety. He should take a warm bath morn- 
ing and evening, and remain immersed during thirty or forty 
minutes, unless he experience a sensation of faintness. The 
effects of this simple bath, in allaying any constitutional irrita- 
bility or feverishness, are highly important, and their agency 
in reducing the glandular engorgement cannot be doubted. 
They should be followed up faithfully. 



260 GONORRHOEA AND SYPHILIS. 

Of the multiplicity of local measures for the treatment of 
adenitis, counter-irritation has acquired great popularity among 
practitioners. It has for many years been employed over the 
swelling in every stage of its progress, as a means of removing 
its contents. The plan proposed by M. Malapert, and which 
has been extensively followed in the hospitals of Paris, con- 
sisted in the application of a blister over the bubo, with a subse- 
quent dressing to the vesicated surface, of a solution, on lint, 
of the bichloride of mercury, in the proportion of twenty 
grains to the ounce of water. This was kept in contact with 
the part for two hours, and afterwards poultices were substi- 
tuted. When the bubo was very large the solution was 
repeated. The success attending this harsh procedure in re- 
moving the swelling, and effecting absorption of the purulent 
matter, even when suppuration has advanced to a considerable 
extent, is acknowledged by those who have been accustomed 
to employ it in all stages of the complaint. The plan, however, 
is now laid aside by many who formerly practised it. It is most 
beneficial when pursued in the formative stage of bubo, and 
when the inflammatory action is moderate. 

A strong solution of nitrate of silver has afforded good re- 
sults. The first systematic trial of this agent was made at 
Guy's Hospital. Mr. Lee, in his edition of Sir Astley Cooper's 
Surgery, states that he never saw a bubo suppurate, when the 
dry nitrate of silver had been applied freely over its surface 
every second or third day. Mr. Henry Thompson confirms 
the statement in regard to the efficacy of the nitrate, which 
he has prescribed in cases of adenitis where fluctuation has 
been so complete and unmistakable as almost to forbid any 
attempt to discuss it on the ground of its apparent hopeless- 
ness.* 

A blister often proves advantageous as a counter-irritant. 
Even where suppuration seems inevitable, the application of 
a vesicatory will sometimes cause the swelling to subside under 
its operation, and perfect resolution will take place ; and the 
case need not be wholly despaired of until the blistering has 
been tried and found unavailing. If the integuments covering 
the tumefaction have become attenuated and of a deep purplish 

* Vide London Lancet, 1855, p. 340. 



BUBO. 261 

hue, thus showing that they are more or less disorganized, and 
are passing into a gangrenous state, then the blister will be of 
no service. Such a morbid condition will require that the 
contents of the abscess be liberated at once, and its walls saved, 
if possible, from further destruction by the employment of 
concentrated nitric acid or a saturated solution of the potassio- 
tartrate of iron. 

There is one other method of treating buboes locally, and 
which I have employed more frequently than any other, in 
cases where I have attempted their early destruction. The 
moment there is a manifest enlargement of the inguinal glands 
as' a consequence of chancre, I direct a blister about two inches 
square to be applied over the tumor. As soon as vesication 
takes place, the cuticle is removed and the denuded surface 
dressed with the following ointment : — 

ft. Unguenti Hydrargyri, § j 

Pulveris Ammonise Muriatis, 3 ss. M. 

The ointment produces some smarting and pain, which, 
however, the patient can tolerate very well, if he keeps quietly 
in his room. In about thirty-six hours a pretty deep sore will 
be formed. This may be dressed with rose ointment for a 
couple of days, the mercurial ointment being laid aside. When 
it has partially healed, the first named ointment is to be re- 
applied ; and this alternation in the dressings should be observed 
until the total obliteration of the swelling has been accom- 
plished, or until something transpires in the progress of the 
case to contraindicate such a course. This plan of local treat- 
ment I consider as good as any, and I have tried all the recog- 
nized methods. I have pursued this with success in many 
instances, but in still more have derived from it no benefit 
whatever; and this, I fancy, is about the truth in regard to 
nearly all topical appliances. 

Collodion has been applied to buboes when there is not 
much local inflammation. It is recommended to be brushed 
over them in successive layers, until quite forcible compres- 
sion is produced. Other methods of exciting pressure are de- 
scribed and practised. In Acton's valuable work are two wood 
cuts, — one showing a truss for compressing buboes, the other an 
inguinal bandage designed for the same purpose. The idea 



262 GONORRHOEA AND SYPHILIS. 

of compression, we are told, had its origin in the accredited 
circumstance or fact that bubo seldom forms on the side on 
which a truss is worn. If it be true that a truss will prevent a 
swelling of the inguinal glands, it does not follow that this 
apparatus, or that a bandage in the style advised by Acton, will 
cure a bubo that has already formed. The great objection, 
however, to the employment of pressure arises from the fact 
that the proceeding is a most hazardous one. Mr. Johnson, in 
his admirable treatise on gonorrhoea and its consequences, 
assures us that he has met with many cases in which he has 
observed bad effects from it. He relates two in detail, and 
which are characteristic of the dangers attending it. One of 
the patients was a young man, the other a young woman. 
Both died, after protracted and dreadful suffering caused by 
the application of bandages and compresses. In both cases, the 
process of inflammation and suppuration, instead of progress- 
ing and terminating in the usual manner in the inguinal glands, 
was intercepted, and pursued divers other routes, establishing 
seats of suppuration and sinuses, involving the iliac fossa, 
bladder, intestines, etc. 

The indolent or chronic bubo may generally be successfully 
treated with small blisters, and the internal administration of 
the iodide of potassium to the amount of half a drachm in the 
day. If absorption does not take place, after a fair trial of 
these measures, the ammoniated mercurial ointment should be 
employed in the way just mentioned. Sometimes this variety 
of glandular engorgement will remain stationary for a long 
period, and then, provoked by some new source of irritation, 
suddenly inflame again, and proceed to suppuration, in spite of 
all measures to the contrary. 

If there be much febrile action, with pain and tenderness in 
the bubo, whether virulent or otherwise, and if the patient be 
of a plethoric habit, some surgeons advise that blood be taken 
from the arm with the lancet, or from the immediate vicinity of 
the bubo by leeches. In nearly all cases, however, it is an easy 
matter to carry the process of reduction to the requisite point 
without loss of blood. Let the patient be subjected to a gruel 
diet and the like for two or three days, and at the same time 
take occasional doses of a weak solution of tartar emetic, and 
his system will be brought to as low a mark as it is safe or 



BUBO. 263 

necessary to conduct it. The symptoms of pain, tenderness, 
etc., which we are now considering, are not occasioned by the 
presence of too much blood in the system, but because, so far 
as the blood has any agency, its equilibrium is disturbed, 
although only in the slightest possible degree. There is, to 
be sure, a remora in the capillaries of the enlarged gland. If 
a few ounces be drawn from the general circulating current, 
the proportional quantity abstracted from the diseased gland by 
this process would be but a drop or two at most, and the loss 
would again be supplied to the parts at once, and thus the 
engorgement would be kept up, unless prevented by other 
means. 

If a bubo should become softened, and give evidence that 
suppuration has occurred, all attempts to bring about a resolu- 
tion will, as already remarked, be very liable to fail. I have 
many times endeavored to disperse the tumor after fluctuation 
has become evident ; but in a majority of cases the suppurative 
process has continued to progress slowly, and I have been 
defeated in the effort to bring about absorption, and have 
regretted that an early opening had not been made. 

For the purpose of giving free exit to the matter, the lancet 
affords the best method. It is more simple and more controlla- 
ble than the Vienna paste or the potassa fusa, and the surgeon 
can instantly release the contents of the abscess by an incision, 
which will not give a tithe of the pain caused by these escha- 
rotics, and will not leave so distinguishable a mark for future 
observation as would be likely to be made by either of these 
substances. The walls of the abscess should be thoroughly 
cleansed with warm water, or with a very weak solution of 
chloride of soda ; that is, one drachm to two ounces of warm 
water. For subsequent dressing, the saturated solution of 
opium should be ordered for the first day or two after the open- 
ing of the bubo. So long as the suppurating surface presents a 
healthy character, and shows a disposition to heal, although at 
a slow rate, the surgeon may look forward to a happy termina- 
tion of existing troubles, and the case need not be regarded 
with particular solicitude with reference to this or that local 
specific. 

The sore should be kept in a cleanly condition. For this 
purpose, as well as with a view to promote its advancement 



264 GONORRHOEA AND SYPHILIS. 

towards a cure, the chlorinated water will be advisable during 
the day, and at night the nitric oxide of mercury ointment 
somewhat diluted. For a simple bubo, ordinary dressings only 
will be required. But when the bubo assumes an unusual char- 
acter, — as, for instance, when its edges show a disposition to 
ulcerate, — when it extends from day to day, or when it 
remains stationary, Ricord and Acton are in favor of the top- 
ical use of powdered cantharides. They recommend that the 
abscess should be filled with the powder, which should remain 
in contact with the diseased surface for an hour or two. If 
induration exist at the edges of the bubo, they advise the mer- 
curial ointment to this portion, while its interior should be 
washed with some astringent lotion. I have never brought 
these suggestions to the test. To me they seem to involve a 
procedure more complicated than will' be found convenient in 
general practice. 

There are many applications which will work a favorable 
transformation in the aspect of an unhealthy, indolent, and 
intractable ulcerating bubo. My predilection is for the ferru- 
ginous solution, which occupies so prominent a position in these 
pages. The strength should vary according to the amount of 
stimulus which the ulcer may need from day to day. At first 
a drachm of the salt to eight ounces of water will generally 
form a suitable preparation for continuous use. As soon as a 
clean, granular surface appears, which usually takes place very 
shortly, the lotion must be diluted so as to contain a drachm of 
the iron to twelve ounces of the water. 

If the iron should not act favorably as a local application, the 
acid solution of chlorate of potash, of the strength already men- 
tioned, may be advantageously substituted. 

Sloughing Bubo. — In this form of bubo the constitutional 
treatment should consist of generous diet, the liberal use of 
wine, chalybeates, ammonia-julep, and at night opiates in suf- 
ficient quantity to procure sleep, and thus remove the irritabil- 
ity of the system, which is apt to be a most annoying symptom. 
Mr. Key {Guy's Hospital Reports) recommends the iodide of 
potassium ; so, also, does Mr. Acton, particularly in serpigi- 
nous chancres and ulcerations. But the latter surgeon holds 
.the potassio-tartrate of iron in higher estimation than any other 



BUBO. 265 

remedy, as may be inferred from the following closing sentence 
from his section on the treatment of phagedenic chancre : " I 
must again repeat that too great stress cannot be laid on the 
admirable results which follow the use of iron in phagedena." 
In brief, it may be remarked that the same treatment which has 
been proposed for phagedenic or sloughing chancre is in all 
respects, both locally and constitutionally, appropriate for the 
cure of the phagedenic or sloughing bubo. 

To the injudicious administration of mercury, and the mea- 
gre, dietetic fare to which patients were subjected, is to be 
attributed the frequency of phagedenic or sloughing bubo in 
former times. Happily it is a variety of ulceration extremely 
rare at the present day. 

Sinuses. — Occasionally it happens, while we are attempting 
to heal a bubo, that a sinus forms, having its opening, or mouth, 
near the most dependent border of the bubo. A portion of the 
purulent deposit works its way downward very gradually, and 
will continue to do this for an indefinite time, unless checked 
by surgical means ; the best of which, in ordinary cases, con- 
sists in the use of an injection of tincture of iodine into the 
orifice of the sinus. The injection may be squeezed out imme- 
diately, and repeated in four or five days, if necessary. One 
injection will frequently close up the whole track of the sinus 
completely. 

If, after a few trials with the iodine, the sinus does not heal, 
the acid nitrate of mercury, in the proportion of one drachm 
to four ounces of distilled water, may be used in its stead, and 
a few drops be injected every day, or every other day. Should 
the latter injection fail to accomplish the desired object, the 
sinus may be laid open, provided it lies immediately under the 
skin, which can be incised without endangering any bloodvessel 
or other tissue. 

23 



CHAPTER XXIV. 

SECONDARY SYPHILIS. 

However scientific and successful the remedial course may 
have been for the cure of indurated chancre, which is the com- 
mon origin of all secondary and tertiary symptoms of a vene- 
real character, it often happens that the virus of this chancre 
steals the march upon the medical attendant, and at an early 
moment finds its way, either by lymphatic or venous absorption, 
into the blood. Here it dwells in a state of incubation for an 
indefinite period before its presence is decidedly pronounced. 
It may remain a long time, and not make known its existence 
by any palpable manifestations, while the individual retains his 
accustomed health ; but if he becomes debilitated, the syph- 
ilitic element will very likely declare itself in some well-marked 
local affection. The period of its latency is wholly uncertain 
and indefinite. It has been known to appear in a few weeks 
in what is called the syphilitic inflammation, or fever, the 
most prominent features of which are seen in the throat, in in- 
flammation and hypertrophy of the tonsils and the adjacent mu- 
cous membrane, neuralgic pains in the head, or pains in the 
larger joints by night, or more frequently perhaps in blotches 
and roseolous congestion of the cutaneous tissue of the face, the 
neck, abdomen, arms, etc. On the contrary, the poison may 
sleep, as it were, in the system for months and years, until 
some exciting agent shall intervene, and bring it from its hiding- 
place to the light of day. 

At whatever period the secondary constitutional development 
occurs, some accessory agent seems to be required to bring 
it forward in a tangible, appreciable form. The most frequent 
accidental cause is exposure to an inclement atmosphere. If 
the patient should work in the open air, or take a ride in a cold, 
stormy day, or remain in a damp cellar, or encounter any try- 
ing vicissitudes of weather for a short time only, the hidden 

(266) 



SECONDARY SYPHILIS. 267 

enemy, which he may have carried about him in embryo for 
years, will be provoked to make known its presence when and 
where it was little expected. 

The average period between the existence of primary chancre 
and the accession of any secondary cutaneous affection, is vari- 
ously estimated. Dr. Egan reckons it at five or six weeks. 
From the cases that have come under my own observation, 
I should say that generally a much longer interval than this 
passed between the chancre and the outbreak of any consecu- 
tive, cutaneous accident. M. Legendre, formerly a pupil at the 
St. Louis Hospital, and author of a thesis on syphilitic erup- 
tions, says : " I have obtained, as a general medium, from the 
time of the appearance of the primary to that of the secondary 
^ accidents (syphilida) five years, precisely the same result as 
that mentioned by M. Martins in his Memoir." 

There are so many differences in the constitutions of patients, 
such diversities of treatment for the cure of the original acci- 
dent, so many varying circumstances in which the individuals 
implicated are placed, such dissimilarities in their personal habits 
and occupations, such gradations, fluctuations, and extremes of 
climate, and such changes in the seasons of the same latitude or 
region, that it is impossible to determine what is the natural term 
of latency which the modified syphilitic virus would observe. 
The primitive, unadulterated, venereal poison, that which gen- 
erates the chancre, obeys a nearly uniform law of incubation ; 
x but the diluted element, that which has been incorporated into 
the blood, appears to be subject to many contingencies, that 
have a direct control over it in producing its visible effects upon 
the constitution. 

Sex has something to do with the interval between the pri- 
mary lesion and the consecutive manifestations. The latter 
developments appear at an earlier day in women than in men. 

Victor de Meric, Esq., reports the cases of nine individuals, 
males, who presented eruptions, and had not undergone any 
treatment. In three cases of papules, the eruption in one ap- 
peared in seven weeks after the primary symptom ; in the other 
the interval had been six weeks ; and in the last, eight weeks. 
Two cases of roseola or efflorescence appeared, one twenty-four 
days after the occurrence of chancre, and the other one month. 
Psoriasis appeared in two subjects at the distance of four and 



268 GONORRHOEA AND SYPHILIS. 

eight weeks. Regardless of the kind of eruption, the author 
here cited reckons a mean of six weeks' time, which separates 
the primary sore from the cutaneous affection, where no treat- 
ment whatever has been resorted to.* The longest interval of 
time between the primary disease and the secondary cutaneous 
affection has been, in my own practice, twenty years. The 
case was an interesting one, and I will here transcribe it chiefly 
from my note-book. 

November 26, 1853. — Dr. H. I. Bowditch, of this city, called 
with a patient of his, and desired my opinion respecting the 
nature of the disease. Upon examination, the limbs, trunk of 
the body, neck and face were found covered with tubercles, 
— most numerous and much the largest on the forehead. 
Here, they were in juxtaposition, and were about two lines 
broad at the base, and were of a dirty reddish brown color. 
The nose, back of the neck, and shoulders afforded the next 
largest crop. On the body and extremities they were sparsely 
disseminated, and were smaller than on the other districts. 
Upon the legs and arms, the eruption approached the ordinary 
lichenoid pimple, and was strictly papular. The man com- 
plained of no suffering or inconvenience of any kind as arising 
from the eruption, except a slight itching or tingling sensa- 
tion when he rubbed his forehead, or pressed his back against 
a chair while sitting. Sometimes the sensation thus awakened 
was like the prick of a pin or the sting of a mosquito ; so said 
the patient. Upon the summit of the papules on the forehead 
a thin scale formed and was cast off every five or six days, as 
in ordinary non-specific psoriasis guttata. Upon looking into 
the throat, the mucous lining of the posterior part, and down- 
ward as far as the eye could reach along the walls of the phar- 
ynx, was found hypertrophied from chronic inflammation. 
The mucous membrane of the whole buccal cavity was oedema- 
tous, and presented a mixture of white and red points, the 
papillae being swollen, and the epithelium displaced from a 
portion of them, and rolled up into white granules. A few 
days before I saw the case, the right tonsil had been removed by 
the late Dr. Samuel Parkman. Previous to the operation, there 

* Lancet, November, 1858. 



SECONDARY SYPHILIS. 269 

had been much difficulty in deglutition and respiration. The 
disease in the throat had existed about one year ; the cutaneous 
eruption came four months later. 

The patient was a tall, gaunt, slenderly-built man, fifty years 
of age, and was extremely pallid. He complained of debility ; 
had a poor appetite ; a feeble, quick pulse ; pains in the large 
joints, and in the head ; his nights were restless ; he stated that 
his health had been declining for more than a year ; he had 
been accustomed to an active life, but was then unable to attend 
to business. He also stated that twenty years ago he con- 
tracted a chancre, was treated without mercury, recovered in 
a few weeks, and was never subsequently exposed to infection.** 
Dr. Bowditch had told this man that his disease was constitu- 
tional syphilis. He ridiculed the diagnosis, as he had been 
in good health for so many years before the present symptoms 
were developed. I confirmed Dr. B.'s opinion. The patient gave 
up his disbelief, and was thrown into no little mental agony. 
He had not a particle of delicacy in regard to his condition 
or the cause of it, and consequently had not the motive of 
shame or mortification to induce him to falsify as to the time 
when he received the virus. At the request of Dr. B., I took 
charge of him, but he shortly went among quacks, and died of 

^syphilitic consumption. To the foregoing instance, I desire to 
append one other, which is not without instruction, although 
the time between the primary chancre and the consecutive 
lesions on the skin, was only eleven years. 

June, 1856. — Patient A. B., age thirty-six years; married. 
Remarkably stout-built, florid complexion, full face, speaks of 
uncommon muscular strength, weight 190 pounds, is of me- 
dium height. In 1844, he was inoculated in the natural way 
with chancre on the under side of the glans penis, near the 
fraenum ; was successfully treated by an experienced surgeon, 

Nand in a few weeks was well. He has led an active life nearly 
ever since as an engineer on the Western rivers, and has en- 
joyed uninterrupted health until 1852, seven years, when a 
moderately sore throat troubled him for a few weeks in the 
autumn ; and on several occasions since he has had an uncom- 
fortable bronchitis in cold, stormy weather. About a year ago 
a crop of tubercles, occupying a portion of integument as 
large as a penny, came on the right temple. Their habits were 
23* 



270 GONORRHOEA AND SYPHILIS 

as follows : Some of them softened and ulcerated more or less 
perfectly, while others gradually wasted away, retaining their 
tubercular character to the last. About the time they disap- 
peared, whether ulcerated or not, a new crop, usually number- 
ing from four to six, was sure to spring up near the borders of 
the cicatrices left by their predecessors. This individual was 
under my care, at intervals, for more than eighteen months 
before the morbid condition of the skin was entirely subdued. 
The disease was a perfectly well marked syphiloderma, and for 
a long time was confined to the right temple. It finally crept 
along just above the superciliary ridge, until it ended at the 
median line by a solitary tubercle, located about half an inch 
above the junction of the eyebrows. Strange to say, this lone 
specimen, which never attained the size of a split pea, main- 
tained its ground more than six months. 

The general health, in the above case, was not disturbed in 
the slightest degree. The patient has a daughter five years old, 
remarkably rugged, and in constitution and features copying 
after the father more than the mother. 

v Thirty years have been known to elapse between the cure of 
chancre and the approach of cutaneous disease as the first con- 
secutive symptom ; and, so far as we have any record, the 
shortest time that has been known to intervene between expo- 
sure and the secondary affection on the skin is three weeks. 
At whatever period the eruption begins to show itself, it is very 
common to find inflammation of the mucous membrane of the 
fauces coeval with it, and extending low down into the throat. 
The patient frequently mentions that he has bronchitis ; and 
the peculiar sound of his voice announces at once that the 
organs of speech are in an unsound state. The vascular 
plexus, both of the mucous and cutaneous membranes, shows 
an increased afflux of blood, and a moderate febrile action pre- 
vails ; but these conditions are rarely suspected by the individ- 
ual as having any connection with his former venereal trouble. 
His complexion presents an unnatural, pale, dirty, or brownish- 
yellow, tinge; there is gradual enlargement of the cervical 
glands ; the skin is wrinkled, dry, and harsh to the touch ; he 
complains of loss of muscular energy, loss of appetite, loss of 
flesh ; has pains in the cerebellum, back of the neck, and in 
the larger joints, especially by night; is nervous, languid, 



SECONDARY SYPHILIS. 271 

depressed in spirits, and rarely obtains sound and refreshing 
sleep. All these symptoms, it is true, may originate in other 
causes, and, taken separately, might not suggest that they had 
any relation to syphilis ; but taken in the aggregrate, and as they 
frequently present themselves in a young man, they are signifi- 
cant of this malady, and there is a meaning and importance to be 
attached to them not to be overlooked by the medical practitioner. 
I have sometimes been amused and astonished at the eloquent 
expression of the patient's demeanor, which serves as a sort of 
tableau, or mirror, declaring, in unmistakable language, the na- 
ture of his malady before a word has been uttered by him, and 
before I have commenced an examination in quest of physical 
signs or marks upon him. I claim no superior tact in this mat- 
ter. What knowledge I have gained is the result of observation ; 
and I share it in common with many others in the profession 
situated as I have been. The physician, however, must not 
allow his judgment, on any occasion, to be biassed by fancy 
sketches. He is to deal with realities ; and when these are 
properly interpreted by him, and he communicates his views in 
regard to them to the patient, he will very likely find the latter 
filled with surprise, and perhaps with incredulity. He has had 

^sio warning or anticipation of such a state of things ; has been 
told, perhaps, that he was thoroughly cured, and safe from all 

Nfuture trouble of a venereal character. This was the fact in 
regard to the two last cases I have related. 

It is incumbent on the physician, therefore, to be clear and 
accurate in the- matter of diagnosis, not only lest he should 
compromise his own reputation, but because the welfare of the 
other party is directly and deeply involved. A chancre or bubo 
is usually recognized without any great difficulty, whatever may 
be the variety of either, unless their real character has been 
greatly modified or wholly lost in consequence of some indis- 
creet medical interference. But far different is the case when 
the keenest eye and the shrewdest intellect are brought in con- 
tact with the dubious pathology of the various consecutive mal- 
adies that affect the cutaneous and mucous tissues, and other por- 
tions of the corporeal system, and which may or may not be the 
offspring of the syphilitic virus. Occasions and circumstances 
will present themselves calculated to bewilder, to astonish, 
and to unsettle the judgment of the physician, however rich he 



272 GONORRHOEA AND SYPHILIS. 

may be in practical experience or logical discipline. I once saw 
a case of chronic eczema, which had been under the care of 
two highly respectable physicians residing in different towns, 
and had been pronounced to be, and treated by both of them as, 
secondary syphilis. The mistake led to very serious difficulty. 
The patient was a married woman of high standing in her 
neighborhood. The husband denied the authorship of such a 
disease. The wife and her immediate friends, guided and sus- 
tained by the erroneous diagnosis above mentioned, believed 
^hini guilty ; and they decided that she should return to her 
parental home, never again to live with her husband. The day 
of separation was fixed ; but, before the measure should be con- 
summated, it was arranged that I should examine the patient. 
This I did, and had no difficulty in satisfying all the parties 
that there was no syphilis in the case. A change at once came 
over the domestic scene. Instead of lamentation and bitter 
wailing, the voice of reconciliation and peace was heard, and 
the contemplated separation did not take place. The above 
historiette is not the only one of the kind that I could relate. 
Its direct bearing, in illustrating the importance of accuracy in 
the matter of diagnosis, will be sufficiently obvious, and for this 
purpose it has been introduced. 

Of all the morbid developments consequent upon primary 
chancre, none are more frequent or interesting, none more 
worthy of careful study, none more difficult to treat, than the 
numerous group comprehended under the nomenclature of 
syphilodermata r which I propose to consider in the ensuing 
chapter. 









CHAPTEE XXV. 

SYPHILODERMATA. 

The plastic hand of " nature in disease " scarcely acknowl- 
edges any limit to the variety of forms which she is able to 
produce from a few pathological types. Especially is this true 
when the human skin is selected as the chart upon which "her 
mysterious operations are delineated. I know that in the mind 
of the general practitioner great confusion, obscurity, and 
doubt sometimes overhang these morbid phenomena like a 
thick cloud. I know also, to some extent, that by patient study 
and critical observation the cloud can be removed, and darkness 
give place to light. In speaking thus, I say no more than the 
student, engaged in the pursuit of any of the natural sciences, 
is able to say in reference to the department of study that may 
occupy his attention. 

In syphilitic Dermatology the elementary forms of disease 
are few, but their modifications are many. 

At whatever period these eruptions may present themselves, 
their manifestation is to be interpreted as an effort on the part 
of the eli initiative powers of the system to get rid of a poison- 
ous element which interferes with its well-being. The disease 
is in the blood. Here it commences its life, as a minute, inap- 
preciable atom received into the vital current by imbibition ; 
and from that moment to the time when the cutaneous derange- 
ment is about to declare itself, it continues to circulate and 
mingle with the various fluids, and to pervade the different 
organs and tissues of the body. The furtive and silent process 
of contamination seems to be endowed with a strange vitality •, 
strange, not by reason of its energy or activity, but by exactly 
their opposite. Its operation is exceedingly slow and gentle. 
It is feeble to an infinitesimal degree, when contemplated in con- 
trast with the activity of the poison of hydrophobia, the virus 

(273) 



274 GONORRHOEA AND SYPHILIS. 

of serpents, of small-pox, of glanders, of dissection wounds, or 
of paludal miasmata. 

Although the ulterior effects resulting from the persistent 
action of the venereal poison may be delayed, the blood at last 
becomes so profoundly deteriorated, that the organism can no 
longer endure the presence and the encroachments of the mor- 
bific principle, — and as is the case with all other poisons, so 
with this, nature institutes a' process with a view to expel it ; 
and although the external investment of the animal economy is 
usually summoned to inaugurate the great struggle of elimina- 
tion, other organs and structures are required to share in the 
labor and participate in the disasters which the enemy is sure 
to inflict. The accumulated poison makes known its presence 
by a development, first in one tissue, then in another, by suc- 
cessive steps and at long intervals ; each tissue and each de- 
velopment presenting a group of symptoms peculiar to itself. 
Hence we can see the propriety and advantage of classifying the 
morbid phenomena of the disease into primary, secondary, and 
tertiary stages or accidents, — an arrangement originally de- 
vised by Thierry de Hery, and recently revived and rendered 
popular by Ricord. In the adult subject, nearly all the syphil- 
itic eruptions belong to the second stage ; a few only are 
reckoned as tertiary manifestations. They all proceed from the 
same original, primitive poison. The syphilodermata of the in- 
fant, who derives the disease by inheritance, are the product of a 
secondary virus, which has been modified, diluted, and weakened, 
in consequence of its admixture with the blood and other fluids 
of the infected parent, before it is transmitted to the offspring. 

Under the influence of the constitutional taint, we have erup- 
tions that are named and known according to the elementary 
forms which they present ; but all these forms exist also, inde- 
pendently of any syphilitic parentage. Ricord does not include 
the bullce among his divisions of the syphilides. He considers 
ulcerous affections as possessing peculiar marks, that are almost 
invariably absolute and distinct from other ulcers. Gibert 
regards the ephelides as entitled to a place among the syphilo- 
dermata ; but the syphilitic origin of such discolorations is 
extremely problematical. 

To all who are familiar with the venereal eruptions, it is well 
known that time brings about important modifications in the 



SYPHILODERMATA. 275 

physiognomy and general characters of these eruptions ; and 
with a view to render them more easy of comprehension, Pro- 
fessor "Wilson, in the last edition of his work on diseases of the 
skin, has classified them in a tabular form, according to their 
chronological development. Thus, the eruptions belonging to 
secondary syphilis are: — 

1. Syphiloderma ErytTiematosum. 

Roseola syphilitica, 
Maculae syphilitica?. 

2. Syphiloderma Papillosum. 

Lichen syphiliticus, 
Lichen pustulosus. 

3. Syphiloderma Tubercidosum. 

Tubercula syphilitica, 
Tubercula ulcerantia. 

4. Syphiloderma Pustulosum. 

Rupia syphilitica. 

5. Syphiloderma Pilare. 

Alopecia syphilitica. 

6. Syphiloderma Ungueale. 

Onychia syphilitica. 

The eruptions belonging to the Tertiary Syphilitic period are 
as follows : — 

1. Syphiloderma Erythematosum. 

Erythema (vel psoriasis) palmare vel plantare, 
Lupus erythematosus. 

2. Syphiloderma Tuberculosum. 

Tubercula mucosa, 
Tubercula ulcerantia, superficialia, 
Tubercula ulcerantia, profunda, 
Lupus ulcerosus, syphiliticus, 
Tubercula gummata. 

3. Syphiloderma Ulcer ans. t 

The Syphilodermata Hereditaria are arranged thus, which is 
the order of their development, in the offspring of syphilitic 
parents : — 

1. Syphiloderma Erythematosum. 

Erythema syphiliticum infantile. 

2. Syphiloderma Tuberculosum. 

Lupus syphiliticus. 

3. Lepra. 



276 GONORRHOEA AND SYPHILIS. 

The foregoing is a list of the maladies which appear upon 
that vast and important organ, the skin, in consequence of the 
venereal affections. At a superficial glance, the number may 
seem large, even formidable and embarrassing ; but it is no 
mere ideal enumeration. It is based upon facts as they present 
themselves with great uniformity in the history of venereal sub- 
jects. And I am confident that the more frequently and atten- 
tively the arrangement is referred to in the study of the syphil- 
odermata, as they come within the observation of the practitioner, 
the higher will be the estimation with which he will regard it. 
There is no nomenclature more classical or scientific in prin- 
ciple, or more in harmony with the cutaneous lesions produced 
by syphilis, than the above. 

The Willanean system is more simple than the foregoing, and 
if we are guided by it, and consider the specific syphilodermata 
according to their elementary forms, we shall have the following 
varieties, which are not at all at variance with Wilson's plan : — 

Exanthematous Affections. 
Macular Affections, 
Papular Affections, 
Squamous Affections, 
Bullous Affections, 
Vesicular Affections, 
Pustular Affections, 
Tubercular Affections. 

DIAGNOSIS OF SYPHILITIC ERUPTIONS. 

Color. — The color of venereal eruptions, in most cases, is 
sui generis. I say, in most cases ; in some instances of genuine 
syphilis this mark or sign is totally wanting. The reddish, 
coppery tint is by no means a constant feature ; and when we 
examine an eruption with reference to its color, allowance is to 
b% made for the natural complexion of the patient, and some- 
times for the influence due to the topical remedies that have 
been employed. The period or duration of the eruption is also 
to be considered. We are to take into the account the particular 
region which is the seat of the complaint. The age of the 
individual and his exposure to atmospheric or solar influences 
will likewise be entitled to consideration. If a person, with a 
roseolous or papular syphilitic affection, be exposed to the action 
of cold, the red, vermilion tinge will be more conspicuous than 



SYPHILODERMATA. 277 

under other circumstances. The temperament and the general 
condition of the system exert an influence upon the color of the 
skin both in health and disease, and should not be lost sight of 
when we examine a patient laboring under a suspicious cutane- 
ous affection. Sometimes the catamenial function has an agency 
in modifying the character of an eruption ; so has pregnancy, 
more especially if the malady be located upon the face. In the 
latter case the color of the skin will be no guide at all in our 
attempts to arrive at a differential diagnosis. The color of syph- 
ilitic eruptions is not uniform. Sometimes it has a violet tint, 
or it may present a coppery appearance, varying in the degree 
of intensity, in the same individual, as the disease progresses 
towards a cure or otherwise. 

At the commencement of an eruption, especially if it be seated 
in a fine, white, delicate skin, the tint may be quite a brilliant 
red, and as the eruption acquires age, and is influenced by 
treatment, it may, and probably will, assume a dark shade, that 
is, a reddish, or yellowish brown. If the diseased skin be 
closely examined when the complaint is in its last stage, or 
when it is in fact passing away, the brown copper color, which 
has for so many years engaged the attention of observers, and 
which is still regarded by many practitioners as characteristic^ 
of syphilis, is usually apparent in a satisfactory degree. But if 
the disorder be in an active state, or in the incipient stage, with 
much roseolar blush upon the general integument, it will often 
prove a vain task to hunt for the pathognomonic copper color of 
the older writers. In some instances, indeed in many, well 
known from other circumstances to be of syphilitic origin, I 
have searched for the existence of this special tint upon the 
integument, and have not been able to detect the slightest trace 
of it. Once it was regarded as absolutely essential to meet 
with the copper stain, or to suspend any declaration of our 
diagnosis, if that diagnosis involved the idea that the affection 
was venereal. But that day, with me at least, has gone by, and 
I can say, " nimium ne crede colori." 

A reddish brown, with a slight ingredient of yellow or orange, 
is the best representative of the dull, copper color, and may be 
considered as a fair exponent of the hue which frequently char- 
acterizes the syphilodermata. It is not, however, an easy matter 
to present a true description or analysis of the various predomi- 
24 



278 GONORRHOEA AND SYPHILIS. 

nating shades and varieties of color that are met with in venereal 
maladies of the skin. To the practised eye, these affections, hav- 
ing any of the peculiar colorations alluded to, are recognized 
with sufficient ease, because these shades or tints rarely ever 
accompany any corresponding diseases which arise from non- 
specific causes. 

In cases where syphilodermata ulcerantia have existed, the 
marks remaining upon the integument may perplex the mind 
of the surgeon not a little. The ulcers of rupia, and the ordi- 
nary ulcerations of syphilis, when they heal, leave behind them 
permanent and ill-looking cicatrices, presenting more or less . 
of a purplish, dirty hue, or a brownish aspect upon the parts 
where the sores have been seated. This condition of the sur- 
face is generally considered indicative of syphilis. It is a con- 
comitant of ulcerative venereal affections very frequently met 
with ; but this brown appearance is also present in non-syph- 
ilitic complaints, where the person is greatly debilitated, and 
"Wilson considers it to be an indication of cachexia, rather than 
of syphilis ; and the frequency of cachexia with syphilis ex- 
plains the occurrence of the coloration. The copper color,'' 
when present, generally affords strong circumstantial evidence 
of a venereal taint in the system ; but sometimes it does not 
warrant any such conclusion or inference. For instance, when 
there is an eruption of impetigo or ecthyma, or ulcers of a non- 
syphilitic character, on the lower extremities, we not unfre- 
quently find, in debilitated subjects, a tendency in the part to 
exhibit a coppery tint, in consequence of the dependent position 
of the limb, and the congested state of the minute cutaneous 
veins, and their remoteness from the centre of circulation. 

I have heard eminent practitioners, both surgical and medi- 
cal, decide that such and such a cutaneous affection could not 
be venereal, because the copper color was not to be found in 
connection with it ; and knowing, as I do, that too much stress 
is still laid upon the circumstance of color by some respectable 
men in the profession, whose calls are far from being restricted 
to the private chamber or to the consulting room, I do not regard 
what I here offer upon the subject as a labor of supererogation. 

But there is another diagnostic sign, more important, more 
constant, and more undoubted than color, and more reliable in 
erery form of venereal eruptions. I allude to 



SYPHILODERMATA. 279 

ANESTHESIA, OR DEFICIENT SENSIBILITY OF THE 

SKIN. 

It is well known to most practitioners that the ordinary, non- 
specific, cutaneous maladies, of every type, and throughout all 
their various stages, are accompanied by itching, smarting, 
tingling, and other painful sensations, in a greater or less 
degree. When a patient has any cutaneous trouble upon him 
that is not venereal, he will, first of all, complain of the itching 
and burning pain which he experiences, especially by night. 
There is always an exaltation of nervous susceptibility in the 
part after the fatigues of the day, and it displays itself in the 
disagreeable sensations just enumerated. So uniform is this 
fact, as an accompaniment of ordinary eruptions, that its 
announcement may be expected as a matter of course. But 
in the syphilides there is entire absence of all these sensations. 
The individual seems to have lost, as it were, all cutaneous 
sensibility. Large districts of integument will be involved in 
a papular, tubercular, or squamous form of disease, which ma}/ 
ultimately pass into broad ulcerations, and these latter take on 
an unfavorable phagedenic or rodent action, — all which would 
be attended with severe suffering in ordinary cases, — and yet it 
is truly astonishing to witness the slight inconvenience which 
the syphilitic patient realizes under these circumstances. "He 
never so much as complains of itching at any period. If ulcer- 
ations are seated over or involve the muscles of locomotion, he 
will complain, of course, of inability to move about without suf- 
fering pain ; but otherwise he would scarcely be conscious of 
their existence, at least so far as any discomfort is concerned. 
It is difficult to explain satisfactorily this almost total absence 
of sensibility in the skin. All we can say is, that it would seem 
that the virus, under the influence of which the syphilodermata 
are developed, has the power of diminishing the normal func- 
tion of the nerve-filaments, or loops, while at the same time it 
affects the nutrition and health of the parts implicated in the 
most serious and detrimental manner, even to their ultimate 
destruction. 

I will not, in this connection, dwell longer upon the insensi- 
bility of the skin when any of the forms assumed by the vene- 
real eruptions are present. To my mind the fact is of more 



280 GONORRHOEA AND SYPHILID 

importance than has usually been attached to it in guiding to a 
correct diagnosis ; it is certainly of more value than the copper 
color, which we have sometimes known to be in the mind's 
eye, and nowhere else. In regard to the itching, or the ab- 
sence of that condition of the skin, the testimony of the indi- 
vidual is always at our command. If he has a complaint of 
any considerable amount upon any part of the surface, and 
reports that it is attended with no irritation, we have very 
strong presumptive evidence in favor of its being a venereal 
disease. In our examination of a doubtful case we can always 
dwell upon this feature, in questioning the person, until we are 
fully satisfied that he has stated the fact as it is, and he can 
never know the drift of our interrogations on this point unless 
we inform him. 

Apart from the copper color, and the absence of cutaneous 
sensibility, there are other features and resemblances which 
distinguish and associate the maladies under consideration into 
a separate class. The solitary patches are uniformly of a 
round figure ; and, when aggregated, are arranged in circles 
or segments of circles. Particular regions also appear to be 
more frequently the seat of the disease than others, as the face, 
alae nasi, forehead, and the back of the neck, especially the 
upper portion, just below the hair and near the mesial line. 
This is the case with nearly all the syphilodermata, com- 
mencing with the papular. When the morbid affection pro- 
ceeds to excoriations, or open sores, the incrustations which are 
formed are thick, and of a dark brown or dark green color. 

A venereal affection of the external surface will sometimes 
pass through all the types or orders before it reaches its state 
of maturity ; that is, it will commence as a mere roseolous blush, 
then become vesicular or papular, tubercular, pustular, etc. 

Cicatrices. — The cicatrices remaining after the ulcerations 
or sores have healed are circular in form, decidedly depressed, 
and in a majority of instances a bronzed color is perceptible for 
several months after the lesions have disappeared. At a later 
period the integument, on which the local disease has existed, 
becomes preternaturally white. If broad patches of skin have 
been involved, the mark that is left exhibits an aspect not unlike 
that occasioned by a superficial burn. 



CHAPTER XXVI. 

SECONDARY SYMPTOMS WITHOUT PRIMARY. 

Before proceeding to the consideration of the syphiloder- 
mata as they appear under different types, I propose to relate 
a few cases which happened in my practice, and which were 
somewhat perplexing to me at the time of their occurrence, 
inasmuch as their origin, or mode of reception, was not con- 
formable to the theory inculcated by Ricord. Such instances 
arise occasionally in the practice of other medical men. In- 
deed, they are numerous ; and the fact is calculated to shake 
one's faith in certain views promulgated by that prince of syph- 
ilographers just named. 

Case I. — Mrs. A., twenty-four years of age, was married 
eight months before I saw her. About three months after 
marriage a small, dry, papular eruption broke out on various 
portions of the skin, but was most abundant upon the forehead, 
face, shoulders, and arms, and upon the palms of the hands. 
The papules were seated on a dusky-red ground, and were of a 
pure lichenoid character. They gradually increased in size, as 
is generally the case, until they became about half as large as a 
common garden-pea at the base. They were discrete, and in a 
few weeks acquired the well-defined anatomical characteristics 
of tubercles in size, prominence, and hardness, and occasioned 
no itching or burning sensation, — in fact, no inconvenience of 
any kind. Upon the tongue were some ten or a dozen well- 
marked mucous tubercles, which came at a later period than 
the cutaneous lesion, and were mostly situated among the cir- 
cumvallate papillae. A preternatural redness, amounting to 
decided erythema, with moderate hypertrophy of the mucous 
membrane of the fauces and pharynx, was distinctly seen. 
The tonsils were swollen ; there was some pain in the throat 
when she swallowed, or inhaled a breath of cold air ; otherwise 
24* ( 281 ) 



282 GONORRHOEA AND SYPHILIS. 

she made no complaint. The husband was of a roving charac- 
ter, and it was known that he had the venereal complaint about 
the time of marrying this woman, who had never before been 
afflicted with any skin disease, nor had she any trouble in the 
genital organs, either antecedent to the symptoms here de- 
scribed, or synchronous with them. The family physician, Dr. 
W. E. Coale, had questioned her on all these points. He was 
well acquainted with the history of both husband and wife, and 
his diagnosis was, that the latter was suffering from secondary 
syphilis. I saw the case with him several times, and fully con- 
curred with him in his views. That this woman ever had pri- 
mary symptoms in the organs of generation there was not a 
particle of evidence. 

Case II. — A few years ago, a young, unmarried man, a 
morocco-dresser, consulted me for an eruption, which made its 
appearance about a twelvemonth before I saw him. He frankly 
admitted that he had been on intimate terms with sundry girls 
of the town, but had never, to his knowledge, had chancre or 
other trouble on the penis or in the groin, nor had he ever had 
any suspicious urethral discharge or soreness. The case had 
been under the care of Dr. Winslow Lewis, who considered it 
syphilitic, and referred it to me as such. 

When I first saw this young man, the complaint consisted of 
tubercles and sores, situated principally on the legs, where they 
were numerous, and in all particulars well marked with the 
usual syphilitic features, which need not here be rehearsed. 
The forearms were the seat of numerous superficial ulcerations, 
resulting from the softening of former tubercles. There were a 
few similar spots on the thighs. The face and trunk were 
nearly free from disease. Several cicatrices, scattered here 
and there upon the limbs, had the characteristic brown stain, 
and were depressed below the adjacent skin, as is the case gen- 
erally where syphilitic tubercles ulcerate and heal. The patient 
had been troubled more or less with sore throat, which came on 
at the time when the cutaneous difficulty was first noticed. He 
was under my care sixteen months before he was able fully to 
resume his employment. I never entertained any doubt in 
regard to the specific character of the cutaneous and other 
symptoms in this instance, nor in relation to the statements of 
the patient as to the non-existence of any primary lesion. 






SECONDARY SYMPTOMS WITHOUT PRIMARY. 283 

Case III. — About a year after the occurrence of the preced- 
ing case, a frail young girl consulted me with reference to an 
extensive crop of pustules and ulcers, which had troubled her 
for more than two years, and which had gone on increasing very 
gradually in severity, and in their terrible work of undermining 
the general health, until she was reduced to a truly miserable 
condition. She was greatly emaciated and enfeebled, and was 
scarcely able to walk without assistance. On the day she called, 
she had travelled by railroad fifty miles, with the expectation of 
being received into the Massachusetts General Hospital, but, in 
accordance with the standing regulations of that institution in 
such cases, was refused admittance. On entering my office, she 
was so exhausted that she immediately lay down upon a sofa. 
She had taken no nourishment for fifteen hours. She was ac- 
companied by a young man, her friend, who lost no time in 
making explanations. 

The skin of this patient, where free from the eruption and its 
indelible imprints, had a leaden hue, with a blending of sallow- 
ness, thus showing a malformation and extreme poverty of 
blood, which frequently, and especially in delicate females, is 
seen to supervene after a long-continued action upon it of the 
venereal virus. So far as the invasion upon the external sur- 
face was concerned, the disease appeared to have a partiality for 
the face, the scalp, the fore-arms, and the knees. Upon the lat- 
ter, three or four broad, superficial ulcers were in a pretty active 
state, requiring the protection of several folds of rag, and ren- 
dering it difficult for the girl to walk. The face was covered 
with numerous tubercles and ulcers, varying in size, and as to 
the different stages they had gone through. Some of the ulcers 
were nearly dried up ; others, more recent, yielded a moderate 
discharge. The countenance was greatly disfigured, and formed 
a living counterpart to the horrible representations we meet 
with in some of the modern treatises on syphilitic dermatology. 
The mouth and throat had undergone equal ravages. In addi- 
tion to the inflamed and hypertrophied condition of the amyg- 
dalae, and the congested state of the fauces and mucous mem- 
branes generally, on the sides of the tongue there were several 
small ulcers. It was difficult for the patient to speak above a 
whisper, and even then the words were uttered in slow succes- 
sion, partly from general exhaustion, and partly, no doubt, 



284 GONORRHOEA AND SYPHILIS. 

because the morbid process had reached the chordss vocales 
and the arytenoid cartilages. The patient knew that her com- 
plaint was syphilis, and she regarded her condition as nearly 
hopeless. She stated that she never, to her knowledge, had had 
primary symptoms. She was free to answer any questions, and 
appeared to have no sense of shame or delicacy. 

Case IV. — February, 1858. I saw, in consultation, Mrs. B., 
a married woman aged thirty-four years, the mother of two 
healthy children. The patient reports that, about eighteen 
months since, an abundant tubercular eruption appeared upon 
various parts of the cutaneous surface. In the course of a few 
weeks, a portion of the tubercles on the limbs began to soften, 
and became pustular ; at a little later period, some of the pus- 
tules passed into superficial ulcerations, but yielded only a 
trifling discharge. The legs, the arms, backs of the hands, and 
several of the fingers are now involved in the disease in its 
different stages. In some spots, hard tubercles, in others tuber- 
cles with a soft or incrusted summit, and in still other places 
patches of lepra syphilitica, are seen. Where the latter are 
partially healed, the integument is extremely livid. The whole 
of the face, including the nose, is now dotted over with hard 
tubercles in juxtaposition, but not confluent. Some of these 
tubercles are unusually prominent. At a distance of a few 
feet, the woman presents the aspect of a person having variola 
at about the seventh day of its existence. There is no sore 
throat, and never has been. During the past two months there 
has been pain in the head and limbs, exasperated by night, and 
greatly interfering with sleep. She states that, some four 
months ago, when she was more feeble than now, her hands 
and feet were as blue as if she had cholera, — were cold and 
swollen. 

Mrs. R. is an intelligent, well-educated woman. She reports 
that she has never experienced any morbid symptoms in the 
genito-urinary organs. She has resided in North Carolina, and 
was there when the present trouble first broke out. She was 
under the care of a highly reputable gentleman, who, in the 
incipient stage of the complaint, regarded it as venereal, but 
subsequently, as the lady states, changed his diagnosis, and con- 
sidered it a simple, non-specific ecthyma. The case has recently 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 285 

been examined by several physicians in Boston and vicinity, and 
they all agree that it is purely venereal. 

I am quite well aware that it sometimes requires no little tact 
to evoke the truth from the polluted recesses of the mind in 
syphilitic subjects. In regard to this tact or skill, I claim only 
an ordinary measure, as I have already confessed. Generally 
speaking, I know that the denial, on the part of the patient, that 
primary symptoms have existed, does not amount to the weight 
of a feather in the scale of evidence, unless it is substantiated 
by other testimony. If this testimony be strongly corroborative 
of the denial, then the statement of the witness, I think, should 
be allowed its full claim to favorable consideration. I do not 
propose, however, to enter into any special pleading in behalf 
of the individuals whose symptoms have been sketched above. 
They have not been introduced in this connection, for mere 
effect, but for the purpose of presenting what I consider to be 
facts in the history of syphilis, and which are important to be 
known by every practitioner who has any professional dealings 
with this strange disease. 

According to Ricord and his school, syphilitic eruptions are 
always consecutive to chancre ; and therefore the subjects of 
the cases which I have related must all have had primary 
chancre. I must say, nevertheless, that no theory or hypothe- 
sis is sufficient to convince me that the facts in the instances I 
have adduced were other than what is stated. If any one will 
consult Wilson, he will find cases similar to those above related. 
Wilson's opinion is, that the syphilitic poison can be taken di- 
rectly into the system through the circulation, without entering 
the lymphatic channels ; and in this way the secondary manifest- 
ations may appear, without antecedents of a primary character. 
He relates the case of a medical gentleman, that is directly in 
point, as confirmatory of what I have stated. I will here tran- 
scribe the last paragraph : " On mentioning to him," says Wil- 
son, " my conviction of his case being constitutional syphilis, he 
told me that, although he had been repeatedly exposed to the 
dangers of contagion from impure connection, he had never had 
a symptom of primary disease, — that is, nothing that ever at- 
tracted his attention, or called for treatment. With regard to 
the disease, there is no doubt as to its nature in my mind ; and 



286 GONORRHOEA AND SYPHILIS. 

I can only come to the conclusion that this case is an illustration 
of absorption of the syphilitic poison by the system, without the 
development of the local or primary disease.'' 

At a recent meeting of the French Academy of Medicine, the 
subject of transmissibility of secondary syphilis was brought up 
for discussion ; and M. Velpeau stated that he did not hesitate 
to maintain that all, or nearly all, the manifestations of second- 
ary syphilis are contagious. He founds his belief of this upon 
the long-standing opinion on this subject, the general assent of 
physicians to its truth, and the daily experience of the profes- 
sion, as well as upon clinical observations, the fact of its heredi- 
tary transmissibility, and the results of inoculation itself. Prob- 
ably no man in the profession has seen more of the operations 
of the " venereal ferment " than Sigmund, of Vienna. He is a 
firm believer in its communicability from secondary affections, 
such as plaques muqueuses, etc. Dr. Henry K. Oliver, of Bos- 
ton, who has recently enjoyed the instructions of this distin- 
guished German professor, states : " I have seen him produce a 
true chancre by inoculation from a plaque muqueuse. He does 
not lay so much stress upon the Hunterian chancre as Bicord 
does, insisting that constitutional syphilis is by no means always 
preceded by an indurated chancre, especially in females. He 
says it is an every-day occurrence for females to enter his wards 
with constitutional symptoms and a chancre quite free from this 
induration ; and he thinks, if Ricord had seen as much of this 
disease in females as he has, he would have become convinced 
of this fact." * Hebra, of the same University with Sigmund, 
teaches the same doctrines to the medical classes. 

Langston Parker relates two instances in which the secondary 
taint was communicated by the husband to the wife. In both 
cases the females were entirely exempt from all disease in the 
urino-genital organs. They were carefully examined with ref- 
erence to this fact, and not the slightest degree of irritation, 
sore, excoriation, or discharge, could be detected in either. In 
both instances the wives had almost precisely the same symp- 
toms that were developed in the husbands. 

Mr. Porter, Professor of Surgery in the Royal College of 
Surgeons, of Ireland, is a believer in the doctrine that lues 

* Vide Boston Med. and Surg. Journal, Aug. 20, 1857. Letter to Dr. J. 
M. Warren. 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 287 

venerea can be communicated by the seminal fluid. " However 
unprepared we may be," says he, " to admit the doctrine, and 
however contrary it may seem to the general laws of the animal 
economy that two distinct — nay, totally different — fluids should 
be vehicles of one and the same poison, I think a careful exam- 
ination of facts will convince any unprejudiced inquirer that the 
seminal fluid possesses this most unhappy quality, and that in 
the mysterious process of generation it may be the medium of 
contamination without the intervention of a single drop of puru- 
lent matter." The facts which this eminent surgeon has ob- 
served are, he thinks, sufficient to establish, as a law of syphilis, 
that the semen of a diseased man, deposited in the vagina of a 
healthy woman, will, by being absorbed, and without the inter- 
vention of pregnancy, contaminate the woman with the second- 
ary form of the disease, and that without the presence of a 
chancre or any other open sore either on the man or woman. 

Mr. Waller, of Prague, published, in 1851, the results of his 
researches on the contagious character of secondary syphilis. 
Among other things he states that inoculation with the secre- 
tion of secondary syphilitic ulcers on healthy subjects may pro- 
duce in them secondary syphilis. Sperino, of Turin, has 
produced syphilis by inoculating with matter taken from sec- 
ondary ulcers. 

Contagion of the Blood. — There are well-authenticated 
instances of secondary venereal symptoms being caused by 
contagion from the blood of an individual affected with second- 
ary syphilis. Waller made an experiment on a lad of fifteen 
years, by inoculating him with the blood of a young girl who 
had had primary sores on several occasions, and who, at the 
time the boy was inoculated, had tubercles on the face, and 
venereal blotches on the surface of the whole body. In thirty- 
four days after the operation a few distinctive venereal tubercles 
were developed near the point of insertion. These were fol- 
lowed by an extensive exanthematous eruption, — that is, a 
characteristic roseola ; and the latter was succeeded by pimples 
and tubercles on various parts of the surface, and which were 
easily diagnosticated as syphilitic. 

That syphilis has been communicated by vaccination admits 
of no dispute. Dr. Alexandre Viennois, pupil of M. Rollet, of 



288 GONORRHOEA AND SYPHILIS. 

Lyons, has devoted much study to this subject, and he cites 
numerous cases in which the venereal poison has been conveyed 
along with the vaccine lymph taken from persons who have had 
latent constitutional syphilis. The venereal infection thus pro- 
duced is derived from a particle of blood accompanying the 
lymph, and shows itself in the development of the papular, 
vesicular, or pustular eruptions, but never in the form of a 
primary chancre.* 

The following report of three cases of venereal disease, origi- 
nating in an infant affected with hereditary syphilis, is from the 
records of the Massachusetts Hospital : — 

Mrs. was admitted to the Massachusetts General Hos- 
pital March 11, 1853, suffering from tertiary syphilis. The 
history she gave of herself is as follows : She had always en- 
joyed good health until seventeen months previous. At that 
time she and her little daughter, a child of nine years, on the 
same day drew the breasts of a woman living in the same house 
with them, and who had for some time been wet-nurse to a 
child which, it subsequently became known to her, was affected 
with hereditary syphilis. The sudden death of this child had 
left the nurse with the inconvenience of over-distended breasts ; 
and it was to relieve her discomfort, on her return to her house, 
that the patient, with her child, several times during one day, 
performed the charitable act above mentioned. The woman 
had, at the time, sore nipples and an eruption on the skin, the 
true nature of which she was ignorant of. In about a week 
from the time of drawing her breasts the patient and her 
daughter began to have very sore mouths, and the throat of 
the patient became so much affected as to prevent her swallow- 
ing anything but liquids. She was under medical treatment for 
a month, taking mercurials, etc., and at the end of that time 
was well of her primary trouble. Twice, since the first attack, 
she has had similar symptoms, in one instance continuing three 
months. At the time of her admission to the hospital her hair 
was quite thin, and the scalp was swollen, painful, and tender 
on pressure in- various places. Her mouth could only be par- 
tially opened ; its roof was slightly ulcerated, and there was 
great hoarseness. Ten months before, a node appeared on each 

* Vide British and Foreign Medico-Chir. Review, July, 1861, p. 54. 



SECONDARY SYMPTOMS WITHOUT PEIMAEY. 289 

tibia ; and that on the left suppurated, was opened several 
times, and had now healed. The one on the right remained of 
half the size of a hen's egg, and was still enlarging and quite 
painful. There had been more or less rheumatic pain in her 
legs for the same period. There had been no eruption on the 
skin, nor any affection of the genital organs. The patient was 
treated with iodide of potassium internally, and by the local 
application of tincture of iodine, and was discharged well on 
the 27th of the following month, there remaining only a trace 
of the node on the right tibia. 

The daughter of the above patient, aged fourteen, entered the 
hospital October 6, 1857. At the time of her mother's first 
attack, she was similarly affected, although with less severity. 
From these primary symptoms she soon recovered under med- 
ical treatment, although she has been several times troubled 
with sore mouth since. Nine months before entrance, she 
presented herself as an out-patient, with ulceration of the soft 
palate and back of the throat. For this she was treated with 
the iodide of potassium and by the local application of tincture 
of iodine without benefit. At the time of her admission to the 
hospital, the ulceration had progressed so far as to have destroyed 
the uvula and a portion of the velum on both sides, leaving a 
triangular opening with ragged edges. The anterior pillars had 
been destroyed. There was much inflammation of the whole 
fauces ; and upon the back part of the throat were large, whit- 
ish patches of ulceration. During the time of her treatment as 
an out-patient her nose had become considerably depressed, 
particularly at the upper part. After admission to the hospital 
she was treated with iodide of potassium and compound infusion 
of gentian, subsequently with tartrate of iron and potash, gr. xx. 
ter die, and by the injection of a solution of sulphate of zinc 
into the nose, the septum having become perforated by ulcer- 
ation. A weak mixture of tincture of iodine and water was 
afterwards substituted for this injection. Under this treatment 
the patient improved, portions of bone coming away at times, 
one of which appeared to be the vomer. She entered under 
the care of Dr. Gay, and passed into the hands of Dr. H. J. 
Bigelow, who continued the treatment, and she was discharged 
well November 25. 
25 



290 GONORRHOEA AND SYPHILIS. 

Transmission op the virus from the nurse to the infant, 
and vice versa. — Upon this subject, M. Trousseau recently 
communicated the following facts and opinions in a lecture at 
the Hotel Dieu of Paris : — 

" I come now to the recital of cases which thus establish the 
possibility of the communicability of the disease from the child 
to the nurse. 

" One of my professional brethren of Paris invited me to a con- 
sultation in the family of one of his patients. He informed me 
that the lady of .the house was delivered, seven months before, of 
a healthy child, which became sick fourteen or fifteen days after 
birth, but without any manifestation of disease of the skin. 

" Toward the end of the second month, and at the commence- 
ment of the third, a cutaneous affection supervened, of a nature 
to suggest the idea of syphilis. A little later, the nurse showed 
on her breast symptoms not at all encouraging ; engorgement 
of the axillary glands of the corresponding side, an eruption of 
roseola over the whole surface of the body, and sore throat. 

" The physician inquired of the father of the child whether 
he had ever had syphilis ; this he denied emphatically. To 
address a similar question to the mother was a thing next to 
impossible ; so my friend was content with satisfying himself that 
she presented no traces of the disease. The nurse grew so 
much worse that it became necessary to confide the child to 
another woman. Three weeks after, the second nurse became af- 
fected in the breast. I was called in a short time after, and sat- 
isfied myself, by my own observation, of the existence of the most 
unmistakable signs of the diathesis. As for the child, it had a 
hypertrophy of the liver, as well as lesions of the skin and mouth. 

" Will you admit that both of these women had been pre- 
viously infected ? This would, to say the least, have been a 
singular coincidence ; but the first of them was a married 
woman and had been remarkably healthy, as well as her hus- 
band, before she began to nurse the child. The second was a 
young girl from the country, confined four months previously, 
and having no knowledge of this disease. Nevertheless they 
were both infected, and both in the same way ! 

" Such facts are very serious, and their number begins to be 
quite considerable. Secondary affections are, without doubt, 
transmitted with much more difficulty than primary ones, but 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 291 

they are, nevertheless, transmitted ; and when communicated 
from the child to the nurse the contagion depends upon special 
conditions, on which I wish to fix for a moment your attention." 

The following quotation from Professor Bennett, of Edin- 
burgh, is worthy of a place in connection with this subject. 
Speaking of syphilis, he says : " The secondary forms of the 
disease are always the result of inoculation ; but this may arise 
not only from the poison being absorbed directly from a primary 
sore, but may be communicated by the mother to the foetus in 
utero, by the infant to the nurse, and again by the nurse to the 
infant. The following case, which was most' carefully inves- 
tigated, and was the subject of legal proceedings, illustrates how 
nurses may be affected by syphilitic infants : 

" In 1842, the late Dr. W. Campbell brought to me a woman 
with a child in her arms, to obtain my opinion whether a skin 
eruption on the latter was or was not syphilitic. I pronounced 
that it was, and that the woman should cease to nurse it, 
although her nipples were at that time in no way affected. The 
child was the offspring of respectable parents, and had been 
sent to her to nurse. In consequence of my opinion, the infant 
was returned to the friends, whose medical attendant maintained 
the eruption to be non-syphilitic. The woman who applied to 
me (nurse 1) was received as wet-nurse into another family, 
and the child was sent to another nurse (nurse 2.) In a week 
the child died ; and a few days afterwards nurse 2 was attacked 
with sore nipples. Nurse 1, shortly after entering her new 
situation, also perceived sores round her nipples ; and the med- 
ical attendant of the family, after consultation with me, caused 
her to be discharged. She, in consequence, brought an action 
against the medical man who had caused the syphilitic infant 
to be sent to her, and mistaken the disease. The lawyer she 
employed then took me to visit nurse 2, whose whole body was 
covered with a syphilitic tubercular eruption. Both nurses 
ultimately succeeded in obtaining compensation from the med- 
ical attendant.' ' * 

In the New York Journal of Medicine for November, 1857, 

Dr. J. L. Smith, physician to the North- Western Dispensary of 

that city, relates an instance of syphilis, communicated from 

a nursling to the nurse. The infant, at the age of five months, 

* London and Edinb. Journal of Med. Sciences, 1852, p. 570. 



292 GONORRHCEA AND SYPHILIS. 

was brought to the dispensary for treatment, and was under Dr. 
Smith's care, as was the— nurse also. The syphilitic character 
of the disease, in both patients, was very apparent. Dr. S. takes 
occasion to cite cases reported by Dr. Bulkley, of New York, Dr. 
Campbell, etc. 

Mr. Holmes Coote, assistant surgeon to St. Bartholomew's 
Hospital, speaking of secondary syphilis, remarks that some 
of the severest cases occur in young and delicate females, in 
whom there is no account of primary disease. He relates cases, 
and he regards secondary syphilis as contagious, and says that 
it behooves the medical attendant to be well apprised of the fact. 

Vidal says : " As to the transmissibility of secondary acci- 
dents, aside from hereditary descent, the doctrine is proved by 
the fact of the infection of the nurse by the child affected with 
consecutive tubercles, and the contagiousness of the mucous 
tubercle in the adult." 

Cazenave, whilst admitting the rarity of the contagion of 
secondary symptoms, acknowledges that it is impossible to deny 
its occurrence, but that certain local circumstances are indispen- 
sable to such a result ; these are a humid or moist secreting 
surface, and prolonged contact. Precisely the views entertained 
and advocated by Sigmund. 

M. Diday regards the lesions of hereditary syphilis as con- 
tagious as primary accidents. 

At a recent meeting of the Boston Society for Medical Im- 
provement, the subject of the communicability of secondary 
syphilis gave rise to an animated discussion, the substance of 
which is reported as follows : — * 

"Nov. 8th. — Communicability of Secondary Syphilis. — Dr. 
W. E. Townsend made further mention of the case reported by 
him in January last, — that of a woman who, two years pre- 
viously, had a venereal ulcer on the breast, followed by second- 
ary syphilis, this being caused by the secretions from the nose 
of a child, which she Was nursing, dropping on a scratch at that 
place. 

"At that time some gentlemen expressed a doubt as to the 
character of this ulcer, thinking the probabilities were against 
its being of a syphilitic nature. 

* Vide Boston Med. and Surg. Journal, January 6, 1859. 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 293 

" Two years and a half afterward, in August of this year, the 
same woman was confined at her full time ; the child at first 
looked well, but in the course of four weeks bullae appeared 
on its ankles and feet, followed by inflammation of the mucous 
membrane of the nose and mouth, filling up those passages 
and obstructing the passage of air and nutriment, in conse- 
quence of which it died within six weeks of its birth. 

" This child died, undoubtedly, of hereditary syphilis, derived 
from its mother. The previous children of these parents have 
been, and are now, stout and healthy, and the father, to the 
best of Dr. T.'s knowledge and belief, never had any syphilitic 
disease. Similar cases have lately been reported by Langston 
Parker, Esq., in his lectures on Infantile Syphilis, in the Lancet 
for August, 1858. 

" Dr. Coale alluded to a similar case reported in the Medical 
Times and Gazette. 

" Dr. Townsend said he regarded the question as to the com- 
municability of secondary syphilis a very important one, as 
bearing on marriage,, the physician being often asked as to its 
advisability, when the husband had had primary disease. 

"Dr. Townsend here briefly alluded to another case. Mrs. 
K., seven months after marriage, had a stillborn child. Two 
years after marriage, she had a second, likewise stillborn. 
Three years after, she had a third at full term, which lived for 
eight months, during five of which it had well-marked infantile 
syphilis. Four years after, she had a fourth, which has never 
been ill, but is still a feeble child, though its mother has always 
been, and is now, a hearty, robust woman. 

" About a year before marriage her husband had syphilis, and 
was attended by a physician of this city, having a large expe- 
rience in such cases. He supposed himself entirely cured, and 
presented no appearance of disease. 

" Dr. Putnam alluded to a case in which a patient, who had 
had syphilis, had supposed himself cured before marriage ; his 
wife gave birth to a child at seven months. There was no 
question as to the nature of the cause. 

" Dr. Abbot mentioned the opinion of Trousseau, that when 
the disease had once existed there is no security against its re- 
appearance in the offspring. Several cases are on record where 
the disease is thus entailed. That there is no certainty as to its 
25* 



294 GONORRHOEA AND SYPHILIS. 

reappearance is evident from another case mentioned by Trous- 
seau, in which the patient, a cavalry officer, who had had syph- 
ilis several times, and was married, had children who exhibited 
no trace of the disease. 

" Dr. Hay ward, Jr., in connection, reported the following 
case, as tending to confirm the theory of the communicability 
of secondary syphilis. 

" In describing this case, the two first letters of the alphabet 
are used to indicate the ladies referred to, but with no refer- 
ence, of course, to their real names. 

"December 17, 1856. — Mrs. A. was confined in the coun- 
try ; she soon had fissures in the left nipple, and her own baby 
not being strong enough to draw the breast well, she borrowed 
one nine weeks old from a poor family in the neighborhood. 
This child nursed her four times. The fissures in a few days 
became sores, and extended until they involved the whole 
nipple. During the first week in April a dark red eruption 
appeared all over her body, arms and limbs ; this gradually 
assumed a copper color, and continued to spread until, by June, 
it involved the whole face. The infant had a similar eruption 
appearing about the same time. 

" July 18, 1857. — Mrs. B., the mother of the above-men- 
tioned patient, came to Boston to consult Dr. Hayward con- 
cerning her daughter and grandchild, and, finding he had gone 
to Europe, she called upon Dr. Hayward, Jr., for advice. From 
the statement of the case given above, which she then made ; 
from the fact that the infant who nursed Mrs. A. died in about 
two weeks after she was taken sick, covered with an eruption, 
and (as she expressed it) ' rotten ' with what the child's father 
said was small-pox ; and from the circumstance that the child's 
father refused to allow any physician to attend upon his child, 
Dr. H. came to the conclusion that Mrs. A. and her infant were 
suffering from syphilis, and requested to have them brought 
to Boston, that he might see them before prescribing. Mrs. B. 
said that her daughter was so mortified at her appearance, her 
whole face being covered with the eruption, that she positively 
refused to travel in any public conveyance. Dr. H. therefore 
prescribed for her hydriodate of potassa and decoction of 
sarsaparilla internally, and black wash, composed of a drachm 
of calomel to eight ounces of limewater, externally ; the infant 
to drink the sarsapavilla, and have the black wash applied. 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 295 

"Aug. 14. — Mrs. B. called again, and reported her daughter 
and grandchild as much better, the eruption very much dimin- 
ished. She was directed to continue the same treatment. Mrs. 
B. at that time supposed herself well. 

" Sept. 11. — Dr. H. was sent for to see Mrs. A., who had 
come to Boston. She had, at that time, extensive traces of the 
copper-colored eruption on her face, and on various parts of her 
body ; but this was dull, except when exposed to changes of 
temperature, and Mrs. A. said that it was steadily fading away. 
She complained of much suffering in the left eye, and, on exam- 
ination, it was found that she had a severe attack of iritis ; the 
attack began in the right eye, and shifted to the left one. She 
had taken the hydriodate of potassa and sarsaparilla up to that 
time. She was then ordered to take a pill, composed of one 
grain of calomel and one third of a grain of opium, three times 
daily, till the gums were slightly affected, and the mercurial 
action was kept up moderately for several days longer. Under 
this treatment the iritis speedily improved, and when she left 
town, Sept. 25, the eye was very much better, and it is believed 
that she had no trouble with it since. 

" On the first or second visit to Mrs. A., at this time, Mrs. B. 
requested an examination of her throat, which she said was 
sore. Dr. H. examined it, and found, to his surprise, that it 
presented every appearance of syphilitic sore throat. On ques- 
tioning her, it was found that she had had the entire care of the 
sores on her daughter's breast, and had sometimes washed cloths 
which came from them ; but that, although she had had little 
cracks about her fingers repeatedly, she had never had any 
sores on her hands or arms until about two months and a half 
before this time. At that time, being about the middle or latter 
part of June, when the baby was six months old, Mrs. B. held 
it while the physician lanced an abscess on the right side of its 
neck ; this discharged freely a greenish-colored matter, which 
ran over her left hand and wrist. On the back of the wrist the 
skin was broken at the time ; and in about a fortnight after the 
abscess was opened, a sore resembling a common boil was formed 
upon the back of the wrist where the abrasion had been. This 
suppurated ; but, when it discharged, Mrs. B. noticed that there 
was no core to it, as in the case of a common boil, and, more- 
over, that the matter discharged from it was of a greenish color, 



296 GONORRHOEA AND SYPHILIS. 

and resembled that which came from the infant's abscess. This 
sore on the back of the left wrist was followed by red and cop- 
per-colored spots, similar to those which Mrs. A. had had, and 
finally by sore throat. The sore throat yielded to fumigations 
of cinnabar and applications of nitrate of silver ; and when that 
was well, she was ordered hydriodate of potassa and decoction 
of sarsaparilla, under which the copper-colored eruption slowly 
improved, though she has been at times troubled with it since, 
and is not quite free from it now. Dr. H. thinks that there was 
no loss of hair in Mrs. A.'s case, and is positive that there was 
none in Mrs. B.'s, except where the eruption was upon the scalp. 
In the course of the treatment, he saw and conversed freely with 
both Mr. A. and Mr. B., and from their appearance and charac- 
ters, and that of their wives, firmly believed that all this disease, 
misery, and mortification arose from suckling a diseased child 
upon a fissured nipple. With this conviction, he remarked that 
it seemed to him of the utmost consequence, first, that, before 
allowing any strange child to nurse a woman, the family physi- 
cian should be consulted, which was not done in this case ; and, 
secondly, that every physician should carefully examine the 
state of a child's health, and also inquire, as far as he is able 
to do so, into the character and health of its parents, before he 
allows it to nurse his patient. 

" Dr. H. J. Bigelow had expressed doubt as to the nature of 
the ulceration spoken of, and had perhaps been alluded to by 
Dr. Townsend. Without at all denying the possibility of the 
venereal lesion and specific secondary contagion in this case, he 
had felt the evidence of it insufficient to justify his own belief 
in it. The additional evidence now presented is, that a second 
child, born two years and a half after the first, presents, in four 
weeks, bullae on the feet, and 4 inflammation ' of the buccal and 
nasal mucous membrane. These symptoms, if specific (which 
is not certain), must have been hereditary at this late period ; 
and this fact of inheritance is adduced as evidence of the pro- 
tracted existence of the lesion in the mother's constitution, 
which, in its turn, is relied on to show that such lesion was 
originally received in a secondary stage from a nursing child, 
and not as a primary lesion from a husband, or from any other 
source. While Dr. B. had great regard for the opinion of Dr. 
Townsend, and, in general, for the sort of conviction which 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 297 

results from a detailed and personal examination of evidence 
of any sort, he did not think that the case cited was one which 
could be relied on to convince other people. Primary lesion, or 
chancre, is always inoculable in an unsyphilized subject. Sec- 
ondary and constitutional lesion is well known to be almost 
never so. The present discussion is to the point whether sec- 
ondary and tertiary syphilitic disease is ever, in exceptionable 
cases, communicable by contact or inoculation. Ricord, after 
years of honest and careful experiment, decided that it was not. 
Subsequent experimenters have since thought that in rare cases 
it may be, and it seems actually probable that it is. But, as 
the comparative ignorance which prevailed in respect to the 
whole subject of syphilis, before the masterly elucidation of 
Ricord, was due to the imperfect analysis of previous evidence, 
justice to the labors of that observer demands a rigorous scru- 
tiny of any case adduced in contradiction of his results. Grant 
a venereal eruption to be identified as such (which is often dif- 
ficult, sometimes impossible), the question of its origin is then 
between a rare contagion from a previous secondary or tertiary 
eruption in another person, and its regular, every-day sequence 
from a primary sore, persistently denied or honestly ignored by 
the individual last affected. No other medical subject presents, 
like this, the sacrifice of character and of social relations as 
obstacles to its elucidation, and evidence should be, weighed 
accordingly. 

" Dr. B. believed that constitutional syphilis was, on all the 
evidence, contagious as well as hereditary, but was rarely so, 
and that the protracted contact of the nursing child was the 
more frequent condition of this contagion. Of course no 
healthy woman should knowingly nurse a syphilitic child, and 
vice versa. As to the question of marriage, he thought that 
the lapse of a year from the complete disappearance, under 
proper treatment, of light constitutional symptoms, and of two 
or three years, more or less, in severer cases, was as strong a 
guaranty of immunity as posterity had a right to expect, or, at 
any rate, as they generally received. 

" Dr. Lyman alluded to the change of opinion in England, 
and on the Continent, upon this subject ; also, to the fact that 
the English journals contain frequent reports of cases which give 
direct evidence of the communicability of secondary disease. 



298 GONORRHOEA AND SYPHILIS. 

" Dr. Durkee considered that the preponderance of medical 
opinion is in favor of the cornmunicability of secondary symp- 
toms. The singular doctrine, advanced some years since by 
Ricord, that, of all venereal affections, indurated chancre 
alone furnished inoculable matter, had been the occasion 
of awakening other distinguished observers to the general sub- 
ject of contagion arising from syphilitic manifestations. The 
facts furnished by such men as Vidal, Velpeau, Trousseau, 
and Cazenave, of France ; by Wilson and Langston Parker, of 
London ; by Professor Porter, of the Royal College of Surgeons, 
of Ireland ; by Sigmund and Hebra, of Vienna, and many other 
high authorities, had now become quite numerous, and they 
were in direct opposition to the views of Ricord. These facts 
are constantly accumulating, and the most respectable medical 
journals teem with well-authenticated instances of infection 
derived from secondary lesions. Two cases of this kind, related 
by Professor Bennett, of Edinburgh, are entitled to our remem- 
brance, whatever theory we may entertain on the subject.* 

" In view of such facts, Dr. D. asked if any member of this 
society would feel justified in giving his professional opinion 
that a syphilitic infant might safely be committed to the custody 
of a healthy wet-nurse ; or, to reverse the circumstances, and 
suppose that a healthy nursling was in want of a wet-nurse, 
and a woman with a large breast of milk should desire the sit- 
uation, but, upon examination, should be found to have second- 
ary syphilis, would any gentleman present be inclined to en- 
courage the friends of the child to commit it to the fostering 
care of such a woman ? 

" Dr. D. remarked that in his own practice he had seen sev- 
eral cases of secondary syphilis, in both sexes, where no evidence 
whatever of primary lesion existed. He considered that the 
proof as to the communicability of secondary lesions was as 
reliable as that relating to the contagiousness of chancre. 
Once he was a believer in Ricord's theory. But facts observed 
in his own practice, as well as those adduced by the most trust- 
worthy men from all quarters of the medical world, had fully 
convinced him that Ricord was not sound on this point. He is 
preeminently entitled to praise for the great scientific advance- 

* These cases are inserted on p. 291. 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 299 

ment he has made in regard to the pathology and treatment of 
venereal affections ; but he is not infallible. 

" Dr. Strong remarked that he did not consider this a ques- 
tion upon which the profession is at present ready to decide. 
Observations were not as yet sufficiently numerous to form the 
basis of a correct opinion. He had for a long time differed from 
Ricord, having seen many cases in which the evidence of the 
communicability of secondary syphilis was undoubted, but was 
yet of the opinion that the time had not arrived to establish a 
pathological conclusion. 

" Dr. Jacob Bigelow remarked that he had been much inter- 
ested in the discussion. There was one point to which he 
would allude, that might tend to reconcile the differences in the 
various reports upon this subject ; and this is the change of 
character that diseases sometimes undergo in different periods. 
Cholera, for example, was formerly a tropical disease ; it being 
only about thirty years since it spread toward the north. 
Plague once visited Great Britain and various parts of the Con- 
tinent, committing terrible ravages ; now it is not known in 
those countries. Yellow fever was supposed, thirty years ago, 
to be non-contagious ; while, at present, serious doubts are 
entertained whether it be not sometimes contagious. Typhus 
fever seems to be at some times contagious, at others not at all 
so. Syphilis had undergone several changes in its character 
within a half century. At one time the doctrine of Hunter was 
well established. Not long after, the chancre was found to vary 
so much as to render it necessary to define what was meant by 
the Hunterian chancre ; and it afterward became so varied in 
character and appearance, as to make it doubtful whether there 
were not as much of qualified or spurious syphilis as of the true 
disease. We know that the contagiousness of small-pox differs 
in different years. Is it not within the bounds of possibility that 
syphilis may, under different circumstances of epidemic predispo- 
sition, be more communicable at one time than at another ? 

" Dr. Strong was not inclined to regard these apparent dif- 
ferences in the communicability of diseases as owing to any 
change in their character, but rather to faulty observation, or 
perhaps to a difference in the predisposition of patients." 

The following interesting case was kindly furnished me by 
Dr. S. L. Abbot, Physician to out-patients of the Massachusetts 
General Hospital. 



300 GONORRHCEA AND SYPHILIS. 



SECONDARY SYPHILIS COMMUNICATED TO AN INFANT 
BY AN ATTENDANT. 

"April 25, 1859. — A little girl, one year old, was brought to 
me by her mother, presenting a well-marked syphilitic affection. 
There were numerous superficial ulcerations on the inner sur- 
face of the cheeks and lips, a slight impetiginous eruption on the 
outer surface of the lower lip and chin, and an abundant growth 
of mucous papules on each side of the anus, passing forward to 
the genital organs, and in both groins. The growth in the 
latter site was very remarkable for its almost perfect symmetry 
of arrangement ; consisting of five or six circular, distinct, 
nummulated patches, each somewhat larger than a half dime, 
rising from one to two lines above the surrounding surface, and 
presenting in their arrangement and grouping almost complete 
identity in both groins. There could be no question as to the 
nature of the disorder. What was its history and probable 
origin ? This was given me by the mother, who had every 
thing in her appearance to recommend her as a worthy, respect- 
able, reliable person, as follows : — 

" Early in the previous October the child was taken with scar- 
latina, and required the care of an extra attendant at that time, 
the mother being too much occupied with her profession — that 
of a dressmaker — to allow her to take exclusive charge of it. 
Her immediate friends and acquaintances were unwilling to ex- 
pose themselves to the contagion of the disease, and she accord- 
ingly availed herself of the services of a woman living in her 
neighborhood, with whom she had but a slight acquaintance, 
but who was recommended to her by her extreme fondness for 
children. She had, it is true, heard disparaging remarks about 
her, but as she was the wife of a man whom she considered 
respectable, she had not given much heed to them. The woman 
was a faithful nurse, very fond of the child, and was in attend- 
ance upon it more or less constantly for three months. During 
this period the child continued to be suckled by its mother. 
The mother observed, at the commencement of the nurse's 
attendance, that she had a very sore mouth, the corners of it 
being greatly disfigured and covered with crusts. Apprehen- 
sive that some disorder might be communicated to her child, 
although not dreaming of the possibility of any syphilitic con- 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 301 

tagion, she questioned her about her mouth, and was told, in 
reply, that the trouble was only l canker,' to -which the doctor 
was applying caustic every day. She did admit, however, that 
some months previously she had had a complaint of a venereal 
character, of short duration, which she had taken from her hus- 
band. She had been well of this, however, for months. The 
natural caution of the mother, notwithstanding, led her to check 
her frequent impulse to kiss the infant ; bat in spite of this she 
frequently observed her disobeying her injunction, and imprint- 
ing her poisonous caresses directly upon the mouth of the little 
one. Her care of the child ceased at the end of three months. 
A few weeks after this, probably about two months, the child 
,vas observed to have sore mouth, which was not considered of 
any special importance by the mother, who looked upon it as 
1 canker,' such as young children are subject to. This contin- 
ued three or four weeks without benefit from the domestic rem- 
edies employed, when the mucous papules made their appear- 
ance. These had existed three weeks at the time the child was 
brought to me. It seemed at once probable that here was one 
of those rare cases of the transmission of secondary syphilis, and 
transmission in a very unusual way. The most thorough and 
searching inquiry failed to elicit any evidence which should 
criminate the parents. Four other children of the same parents 
are living and perfectly healthy, and have never shown any 
symptoms like those recorded above. The father admitted that 
he had had gonorrhoea fifteen years since, some years before his 
marriage. He was previously unknown to me ; but the frank- 
ness of his manner, and the extreme solicitude of both parents 
in behalf of the little one when they learned the real nature of 
her affection, had great weight with me in satisfying me that 
they could not, knowingly at least, have had any direct connec- 
tion with the infliction of this grievous disorder upon it. In 
order to supply all the evidence possible, the mother submitted 
most willingly to examination, and not a trace of disease, recent 
or old, could be found on the external organs of generation, or 
by specular exploration of the vagina and Uterus. No evidence 
therefore existed to implicate the parents. It was highly desir- 
able, if possible, to obtain an examination of the woman from 
whom the evil was supposed to have sprung. Luckily she was 
within reach, and without hesitation presented herself to me for 
26 



302 GONORRHOEA AND SYPHILIS. 

examination, and, judging from her semi-indignant manner of 
address, for acquittal from all suspicion. She admitted at once 
the fact, that had been previously stated, of a venereal complaint 
of short duration, of which she recovered some time before 
taking charge of the child. The complaint, she said, was a 
slight ' running ' from the vagina, which lasted but a few days. 
She was treated by her husband (who, according to her account, 
pleaded guilty to imparting it to her), he having had some ex- 
perience formerly in compounding medicine in an apothecary's 
shop. The occurrence took place soon after their marriage, and 
the disease in the husband was said to be the remains of a dis- 
order contracted before marriage, of which he had supposed 
himself cured. Her mouth was still sore, she having tried 
various physicians without relief, all of whom called her dis- 
order ' canker.' The angles of the mouth were ulcerated and 
swollen, bearing evidence of the long duration and treatment 
of the disease ; there was a superficial ulcer, as large as the 
nail of the little finger, and covered with lymph, on the inner 
surface of the lower lip, which she ascribed to the pressure of 
the teeth ; just within the angles of the mouth, on the inner siir- 
face of both cheeks, were similar ulcers, with turgid, indolent 
edges. I unhesitatingly assured her that she had syphilis in its 
secondary stage. The ulcers were identical in appearance with 
those so often seen accompanying syphilitic sore throat, and 
which are so apt to continue, now better, now worse, for a 
tedious period. Her mouth, she said, was in about the same 
condition as when she had charge of the child. There was no 
affection of the throat nor any indication of former disease 
there ; neither did I see any trace of cutaneous disease. The 
child's mother, however, had informed me that she noticed a 
scurf on her hands at the time she was in her employ. On 
farther inquiry, I learned from the woman that she had miscar- 
ried three times within a year, each time before the completion 
of the third month of pregnancy. After one of these abortions, 
the occurrence of which she attributed to weakness, she lost her 
hair, owing, as she thought, to the subsequent fever. I did not 
make any further examination, as information which I had 
received of her history subsequent to the time when she had 
charge of the child made any facts which might have been thus 
obtained of no special value. This, then, is the whole history, 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 303 

and I am unable to resist the conviction that the child derived 
its disease from her attendant, who was affected with it at the 
time, probably, in a secondary form. The difficulty of obtaining 
final, irrefragable evidence in such a case is, of course, ex- 
tremely great, almost amounting to an impossibility ; but, if 
circumstantial evidence can insure conviction, we have here, I 
think, a very strong case. 

" It may be said, granting the fact that the woman had syphilis, 
how do you know she did not have chancre in the mouth, from 
which the disease was communicated to the child ? It is ex- 
tremely improbable that she had for two reasons : first, the 
assurance of the mother and the woman herself that the disorder 
in her mouth is in the same condition now as it has been since it 
first appeared, — a statement made of course without any knowl- 
edge of its professional significance, and according with the 
well-known facts in similar cases ; and, second, there is no evi- 
dence that the child has had any different affection of the 
mouth from that existing when I first saw it, and which did not 
appear until some weeks after all intercourse with the woman 
had been broken off. 

"Furthermore, it is noticeable that the disease in the child is 
not the usual hereditary form. In the great majority of cases, 
that appears as roseola or psoriasis, with ulcerations, etc., and 
almost always shows itself within the first few weeks after birth. 
To be sure there are exceptions to this, but they are of extreme 
rarity. 

" It should be remarked that the left nipple and areola of the 
mother were inflamed and slightly excoriated at the time the 
child was brought to me, and had been so for some days ; and 
the mother stated that she nursed the child almost wholly from 
this breast. There was no fissure or ulcer, only an inflamed 
and superficially excoriated appearance. The facts in the case, 
then, may be summed up as follows : — 

"1. A previously healthy child is taken in charge by a woman 
who at the time has ulcerated lips and mouth. 

" 2. This woman admits the previous existence of a venereal 
complaint (as likely to have been a concealed chancre as any 
thing else from her account), from which she had some time 
before recovered. She acknowledges repeated abortions and 
alopecia, — common enough results of constitutional syphilis. 



304 GONORRHCEA AND SYPHILIS. 

She still has, at the time of examination, indolent ulcers of the 
lips and cheeks, such as are so often seen in secondary syphilis. 

" 3. The statement of the mother that, in spite of her earnest 
remonstrances, the attendant frequently kissed the child's lips. 

" 4. The occurrence after a few weeks' interval of superficial 
ulcers in the child's mouth, followed soon after by mucous 
papules and inflammation and excoriation of the mother's 
nipple. 

" Such are the facts, and their value will be different with dif- 
ferent minds. I am willing to admit that I believe the child to 
have contracted syphilis from the impure lips of her attendant, 
she being at the time affected with secondary ulcers of the 
mouth, the first manifestations of the disease in the child having 
the secondary form. 

"It remains to say a few words of the treatment of the case. 
The mother was advised to wean the child, for fear of the con- 
sequences to herself; and, until that was accomplished, to wash 
the nipple with liquor sodse chlorinatse, after each application of 
the child to the breast, and to wash over the excoriated surface 
daily with a solution of nitrate of silver, four grains to the 
ounce of water. Two grains of the chlorate of potash were 
directed to be given to the child three times daily, the same 
solution of nitrate of silver to be applied once daily to the con- 
dylomata, and black wash to be kept constantly applied to them. 
The mother's nipple was well in five days, and at the end of two 
weeks the child was greatly improved. The change of diet had 
been any thing but prejudicial to it, and the mother expressed 
her astonishment at its rapid increase of flesh and strength. 
The papules had become very pale, and had subsided about to 
the level of the surrounding surface, and the mouth was nearly 
w T ell. The treatment was directed to be continued until recov- 
ery should be complete.' ' 

The general bearing of what is embraced in the present chap- 
ter, it will be seen, goes directly to impeach the doctrine of 
Ricord, who steadfastly maintains that indurated chancre alone 
can produce consecutive or constitutional accidents, except in 
hereditary syphilis. In a legal and moral, as well as in a med- 
ical, point of view, the subject is one that demands close and 
impartial study. Its investigation is acknowledged to be fraught 



SECONDARY SYMPTOMS WITHOUT PRIMARY. 305 

with difficulties. It is not wholly free from the influences flow- 
ing from the schools and the high authority of brilliant names, 
and it is perhaps impracticable to sever it from such relations. 
As in many other matters not susceptible of mathematical 
demonstration, so in this, the evidence that convinces one man 
may fail to satisfy another ; and thus the question seems likely 
to remain a mooted point at least for the present. I consider 
myself justified, however, in stating here that, in the judgment 
of a vast majority of the most eminent men in the profession, 
the communicability of secondary syphilis is a fact as firmly 
established as is the contagiousness of the poison of indurated 
chancre. And whatever may be the theoretical notions of the 
reader on the subject, he will do well, whenever he is called 
upon to form a diagnosis, or to give an opinion in matters of this 
sort, wherein the health or the character of individuals or par- 
ties is at stake, to ponder upon the facts and opinions embraced 
in this chapter. To ignore them would be unreasonable, un- 
safe and unjust. 

The theory has been broached by Simon, an eminent patholo- 
gist, that the primary syphilitic poison is insoluble, and that it 
will not act through a continuous membrane ; and that the 
poison of secondary syphilis, on the contrary, is soluble, and 
acts, as is seen in its influence on the foetus in utero, through 
the unbroken walls of the bloodvessels by endosmosis, convert- 
ing into its own likeness those materials of the blood with 
which it comes in contact ; and why may not the process be the 
same in the adult subject ? 
26* 



CHAPTER XXVII. 

SYPHILODERMA ERYTHEMATOSUM, OR ROSEOLA 
SYPHILITICA. 

The exanthematous affections, including the maculae, roseola, 
erythema, and, according to some dermatologists, the ephelides, 
are the first manifestations of constitutional syphilis upon the 
skin. 

Roseola syphilitica is the principal eruption we meet with, 
either as accompanying primary symptoms, or as a precursor 
of other secondary accidents which supervene at a later period, 
particularly the papular or tubercular affections. Roseola is 
the simplest form of cutaneous affection, and is not very un- 
common after the existence of chancre. It usually commences 
without any feverish condition of the system. The patient is 
surprised to find the color of the skin changed to red, without 
having experienced any antecedent constitutional disturbance. 
In some instances, especially in plethoric subjects, the eruption 
of roseola, of lichen, etc., is ushered in by a slight febrile ex- 
citement. Sometimes, as I have elsewhere stated, a species of 
urticaria, or lichen, is seen upon the whole surface in conse- 
quence of the peculiar action of balsam of copaiba, or of the 
powder of cubebs, taken in large quantities for the cure of gon- 
orrhoea, by persons having an extremely delicate skin, and who 
are accu&tomed to drink large quantities of wine, and to other 
high living. In these circumstances the man takes alarm, and, 
presuming the cutaneous disorder to be dependent upon the 
urethral discharge, and indicative of real syphilis, he imagines 
that a chancre must be lodged in the urethra. I have recently 
met with two such instances. In one, no little consternation 
was felt by the patient, because he apprehended that his habits 
and his condition would come to the knowledge of his imme- 
diate friends. But upon the discontinuance of the medicine, 

(306) 



SYPHILODERMA ERYTHEMATOSUM. 307 

the peculiar erythematous excitement of the integument en- 
tirely faded away. 

In the early period of the eruption the roseate tint of the 
surface, retiring for a moment under the pressure of the finger, 
masks the characteristic coppery hue ; hut, as it acquires chron- 
icity, the color diminishes only in a slight degree, and then the 
true nature of the affection is more distinctly declared. When 
it occupies the whole of the face, the abdomen, and other exten- 
sive regions, it has very much the mottled aspect of measles ; 
and it then comes out in circular or crescentic blotches, is un- 
accompanied by constitutional symptoms, and is free from itch- 
ing. Again, it will appear on one part of the skin, and, after a 
short period, — say from eight to ten days, — will vanish, and 
show itself at quite a distance in some other district ; thus mi- 
grating from spot to spot, and exhibiting its dusky shade espe- 
cially on the lower extremities, where the cutaneous capillaries 
are more readily congested than elsewhere. 

Not infrequently, instead of a coppery red, the eruption 
assumes a yellowish red, constituting the salmon-colored skin, 
and, as the disease lessens, there is a moderate epidermic exfo- 
liation. The integument will present a grayish tint, which is 
due to the partially-detached scales of epidermis resting on a 
dark red base. To the eye it seems elevated above the adjacent 
sound skin ; but, if the fingers are passed along the surface, no 
elevation can be perceived. The skin feels nearly as smooth 
and even to the touch as in health. When the eruption termi- 
nates it leaves a peculiar dingy stain (macula syphilitica) , which 
lingers for several months before it is entirely effaced. The 
spots present variations in the intensity of hue, from time to 
time, during the progress of the disease ; but, however deep 
and well marked the discoloration may be, it always lacks that 
bright scarlet which belongs to simple roseola. Sometimes it 
assumes the annulate form. This variety, however, is uncom- 
mon. I have met with two instances, both in females, one of 
whom, a noted actress, was of a full, plethoric habit, and suf- 
fered several weeks from the eruption. It occupied the arms 
and chest principally. The mucous tissues were unaffected. 
The other was that of a respectable married lady, infected by 
her husband, and suffering from primary sores at the same time. 
The eruption appeared upon the face, neck, and extremities ; 



308 GONORRHOEA AND SYPHILIS. 

and several months elapsed before the woman was cured of 
either form of complaint. 

Roseola syphilitica sometimes presents a punctate form, in 
which the follicular congeries of capillary vessels is congested. 
The sub-occipital and other cervical lymphatic glands are usu- 
ally swollen in cases where this cutaneous affection is spread 
over a large extent of surface. The sudoriferous pores are also 
prominent, and the sebaceous follicles obstructed by a dry sor- 
des, consisting mostly of epidermic particles. The skin is in an 
unperspirable state, or, if covered with insensible perspiration, 
it exhales a peculiarly disagreeable odor. This latter idea is 
denied by some writers, but I think it is founded in truth. 

Diagnosis. — From the preceding description, which embraces 
the leading features of true roseola syphilitica, it would seem 
that the diagnosis cannot be surrounded by any great difficulty ; 
and yet well-marked examples of the malady have been mis- 
taken, in the early stages, for rubeola. An instance of the kind 
occurred within my observation not long since. The person was 
a married woman, who, as well as her husband, denied ever hav- 
ing had any venereal symptoms. After the eruption had existed 
for several weeks, Dr. Salter and myself were called in consul- 
tation. The posterior cervical glands were enlarged ; the mu- 
cous membrane of the mouth was inflamed, and upon it were 
several small ulcerated patches ; there was great constitutional 
debility. Notwithstanding the parties denied the existence of 
primary specific disorder, either past or present, the cutaneous 
affection, which covered nearly the entire surface, was now suf- 
ficiently distinct in character not to be confounded with any 
other exanthem, especially when considered in connection with 
the other concomitant circumstances. The patient had never 
before been troubled in this manner. Several months passed 
before her recovery. 

In rubeola the abnormal conditions are of an acute form 
from the commencement of the attack, and reach their acme 
rapidly. Although the efflorescence of the integument in 
measles and in roseola syphilitica may present a similar aspect 
to the eye, it should be remembered that in the latter disease — 
the coryza — the profuse serous discharge from the eyes, the 



SYPHILODERMA ERYTHEMATOSUS!. 309 

cough, the sneezing, the quick pulse, and the alternation of 
chills and fever, which exist in measles, are wanting. 

Treatment. — If any febrile symptoms are present, which is 
seldom the fact, a mild antiphlogistic treatment, pursued for a 
few days, will subdue them. The simple warm bath should be 
daily administered, or a bath containing sulphuret of potash 
in the proportion of two ounces to thirty gallons of water. The 
therapeutic benefit which can be derived from warm bathing 
and warm-water douches, as powerful means of stimulating the 
cutaneous vessels to healthy action, will in the generality of 
cases be manifest in a satisfactory manner. The occasional use 
of soap with the bath will be serviceable. In many instances, 
where this simple variety of disease is present, minute pellets of 
hardened epidermis and sebaceous matter form at the orifices of 
the sudoriferous tubes, and impart to the surface a peculiar 
roughness. This dry scurf has a constant tendency to accumu- 
late; and to obviate this, bathing, with liberal friction, should be 
faithfully attended to. The gelatine bath and bran bath are 
sometimes recommended. Of course there is no objection to be 
urged against their employment if the patient choose to try 
them ; hut I am not aware that they possess any special virtues 
not inherent in the other modes of purifying and exciting the 
external surface. 

Moderate saline evacuants, combined with tonics, and a 
generous diet, exposure to a pure atmosphere, and regularity 
in the habits of the patient, is all that will be required at this 
crisis by way of constitutional treatment. 



CHAPTER XXVIIL 

PAPULAR ERUPTIONS. 

Syphilitic papules exhibit themselves under the guise of two 
principal forms. In the one, they are closely associated together 
in groups, and assume a semilunar or crescentic arrangement, 
with intervening healthy spaces, and the spots or patches look 
not unlike so many dusky-red, fleecy clouds, in miniature. The 
other mode in which the papules appear consists in a widely 
disseminated arrangement. In the latter, T think it is correct to 
state that the individual papules are larger than when de- 
veloped in crowded clusters. The usual size is, at first, about 
that of a common pin's head. Whatever their form, or size, or 
mode of distribution may be, however, they are endued with the 
tawny or coppery red color which is so generally, I cannot 
say always, characteristic of venereal eruptions. At no period 
are they pruriginous, even when they terminate, as they some- 
times do, in desquamation of the epidermis which covers them ; 
and they le*ave behind them, for a very long period, stains of a 
brown coppery color, or the hue of the brown faded leaf, as 
the remembrancer of their former site. Sometimes syphilitic 
papules spring up in great abundance upon the forehead, 
usually in clusters of ten or twenty ; at other times they are 
quite isolated. When thus developed, they bear a close resem- 
blance to acne indurata, and have been honored with the digni- 
fied sobriquet of cor ana veneris. They create no constitutional 
disturbance, unless they burst forth suddenly as an acute affec- 
tion, which is not often the fact. When they do thus appear, 
however, the febrile condition is well pronounced. There is 
increased temperature of the surface, which is very rough, and 
in an unperspirable state ; the pulse is accelerated, and the 
tongue parched and coated. But the moment the papular 
development is complete, the constitutional struggle subsides, 
and the economy seems to be relieved, or entirely at rest. 

(310) 



PL IT. 




,.. X »** 9 /> v - 






Syphilitic Lichen 



PAPULAR ERUPTIONS. 311 

The chronic variety is extremely prone to make successive 
invasions. From the time one crop of papules has been sub- 
dued, not many months will elapse before another will be very 
likely to show itself, unless the treatment has been followed up 
without interruption or abatement for several weeks after the 
skin has been restored to a normal condition. In regard to the 
obstinacy of the attacks, something depends upon the period 
that has intervened between the primary affection and the con- 
stitutional symptoms. If the former have been recently cured, 
the eruption will prove less intractable than in those cases 
where a long interval has passed between the primary and 
consecutive disease. The treatment pursued, the state of the 
system, and the habits of the patient, are likewise so many con- 
tingent circumstances which will more or less influence the 
persistence of the eruption ; so that nothing very definite can 
be predicated on this point. 

In passing the finger over the affected portions of skin, the 
papules will feel perfectly solid, like so many shot, or like millet 
seeds. They are known as lichen. Where they are arranged 
in clusters of various dimensions, they are denominated lichen 
corymbosus ; where they appear separately, they are termed 
lichen disseminatus. Professor Wilson makes still other vari- 
eties, according to the particular mode of development ; but 
these subdivisions I do not regard as very important in this 
connection, and for the sake of avoiding confusion I shall not 
introduce them here. [Plate II.] 

Diagnosis. — The erythematous blush with which the mu- 
cous membrane is suffused, and which is often the foreshadow- 
ing of the ulcers that invade it in constitutional syphilis, is 
associated with the papular development now under consider- 
ation. The pendulous veil of the palate, the uvula and fauces 
generally, including the tonsils, are usually inflamed. The 
conjunctiva is likewise deeply reddened, and the lids more or 
less tumefied. The breath is disgustingly foetid, and the lingual 
papillae are elongated and turgid. These symptoms are avail- 
able as so many well-known signs or aids which we can bring to 
our assistance when we are about to form a diagnosis as to the 
character of the complaint ; and it would seem that the abnor- 
mal condition of the several parts of the mouth and mucous 



312 GONORRHOEA AND SYPHILIS. 

membrane of the eyelids, joined to the phenomena spread out 
upon the superficies of the trunk and limbs, could not fail to 
conduct the mind of the medical observer aright ; for these 
appearances do not exist in any non-specific disease. The 
practitioner should never neglect to make a careful examination 
of the mouth and throat before coming to a decision in regard 
to the nature of the cutaneous disorder. 

By an easy transition the elevated papules of lichen, in each 
of the varieties which it presents, may pass into the tubercular 
form, which is one of the most common and important of all the 
syphilodermata. Very often the papules are seen in company 
with pustules, tubercles, or squamae ; or the patient may present 
himself with the types of nearly all the syphilitic eruptions upon 
him. The lichen is frequently associated with iritis, nocturnal 
pains in the large joints, or with some other manifestations of 
constitutional syphilis. Occasionally, it arises as an accompani- 
ment of the primary symptoms, and, in such cases, is apt to 
awaken a febrile disturbance for a few days. Sometimes it 
attacks the prepuce of the male, or the vulva, orifice of the 
urethra, or clitoris of the female ; the external surface of the 
labia is also frequently dotted over with this eruption. When 
seated on the organs of generation, it will sometimes excite 
considerable irritation and soreness of the parts. In some 
instances the papules inflame, and minute ulcerations appear 
upon their apices, which soon become covered with dry, delicate 
scabs or incrustations. "When developed upon the extremities, 
or upon the inferior portion of the abdomen, this eruption has 
been erroneously supposed to be a syphilitic form of itch ; hence 
the name of scabies venerea, mentioned by some of the older 
writers. Although there is no such malady as venereal itch, 
we occasionally meet with the vesicles of simple eczema 
mingled with the papules of syphilitic lichen. 

The lichenoid papules are more frequently present in the 
adult than any other form, of syphilitic disease. In the infant 
they are not often observed. When the affection is developed 
upon the face, the innumerable pimples impart to the coun- 
tenance a dark, cupreous, shining and ludicrous appearance. 
When it is confined chiefly to this locality, it is often ex- 
ceedingly difficult to ascertain its real character, so far as our 
dependence for proof is placed upon the eruption itself; and 



PAPULAR ERUPTIONS. 313 

the most practised eye will be unable to identify the disease as 
syphilitic or otherwise. Especially will this be true if it have 
passed into the squamous condition. The shrewdest practition- 
ers have fallen into error in their diagnosis. So difficult is it 
to arrive at the truth, that Acton does not place any confidence 
in evidence derived from the state of the skin. He and several 
other surgeons once made a mistake, in consequence of which 
he has inserted the following sentence in his work : " This case 
led me to trust alone to concomitant symptoms, and I deter- 
mined never to characterize a papular eruption as syphilitic 
unless it was attended with other well-marked symptoms, such 
as psoriasis palmaris, sore throat, or mucous tubercles." The 
same intelligent writer relates an instance in which his distin- 
guished master, Ricord himself, came to a wrong conclusion, as 
was proved by the subsequent history of the symptoms, and by 
the treatment of the patient. At the time Ricord examined 
him, he had, along with other suspicious symptoms, psoriasis 
palmaris, etc. ; but, because no evidence of a former chancre 
could be obtained, Ricord, true to his long-cherished but falla- 
cious theory, pronounced that the disease was not syphilitic. 
Acton treated it successfully with mercury, and regarded it as 
venereal. 

After the healing of a chancre, the syphilitic taint will remain 
in a latent state for many years, without disturbing the healthy 
condition of the system in any way, and then manifest its 
presence and its specific action in a very feeble manner upon 
some portion of the skin, usually the face. It commences with 
a small patch of hard, dull-red papula?, located upon one cheek, 
or upon one of the temples, where it lingers for many weeks, 
perhaps, without betraying any disposition to spread, some of 
the papules gradually passing into a pustular state, and some 
of them being covered with squamag, without assuming the 
usual pustular character. Otherwise, the entire surface looks 
perfectly healthy. This insignificant disc, perhaps not an inch 
in diameter, may constitute the only external manifestation of 
the expulsive effort of nature to relieve herself of the " peccant 
humor," which she has, until now, retained within her pre- 
cincts with impunity. The syphilitic features of the eruption 
are generally well developed in these minor patches, amid the 
transitions which they undergo. During the continuance of 
27 



314 GONORRHOEA AND SYPHILIS. 

this trifling cutaneous affection, a- morbid state of the buccal 
mucous membrane very commonly coexists. On examination, 
the fauces will be found swollen and of a purplish hue, but 
perhaps giving the individual no trouble. The medical attend- 
ant, however, will need a reliable history to aid him in the 
diagnosis. These cases occur with considerable frequency. 
The therapeutic principles, upon which the most successful 
treatment is based, are abundantly simple. Every day's expe- 
rience, as realized both in public and private practice, bears 
testimony to this. 

If the lichen be acute, and appear as an accompaniment of 
primary symptoms, it can generally be ameliorated or entirely 
subdued by means of plain warm-water baths daily adminis- 
tered ; or what is termed the emollient bath may be used in its 
stead. This is prepared by pouring four quarts of boiling 
water upon two quarts of wheat bran, and, after allowing it to 
stand for half an hour, let it be added to the bath. In the 
acute variety of the papular syphilide this will be found par- 
ticularly beneficial in allaying any irritability of the skin or 
any inflammatory action, either local or constitutional ; will 
rarely fail to mitigate the eruption, and to keep at bay any ten- 
dency to its increase. The sulphureo-gelatinous bath is also 
valuable. It will be found preferable to the artificial Bare'ges 
bath, which is liable to occasion too great excitement in the 
cutaneous vessels. 

The sulphureo-gelatinous bath is thus prepared : — 

R. Potassii Sulphureti, § ij. 

Aquae, Cong. xxx. 

Add to this solution : — 

Ichthyocollae, lb. ij. 

Aquse Bullientis Solutae, lb. x. M. 

The potash had better be omitted for the first few times, until 
the turgid condition of the capillaries has diminished, after 
which it can be advantageously added. One or the other of 
these baths, according to circumstances, should be employed as 
auxiliary to other antiphlogistic measures. 

In the acute variety of lichen, there is usually considerable 



• PAPULAR ERUPTIONS. 315 

derangement in the chylopoietic viscera ; and this state of 
things must be rectified, otherwise the skin will remain unim- 
proved. The Congress Spring water, under these circum- 
stances, frequently constitutes a valuable beverage for the 
patient. It acts as an efficient evacuant on the kidneys or 
bowels, or both. I always prescribe it, if the individual can 
afford the expense which its use involves. It is a capital tonic 
to the digestive apparatus, while it is sure, also, to act with 
energy and safety on the emunctory system.* 

The liquor ammoniae acetatis can likewise be employed to 
advantage. It is an excellent diaphoretic ; and, prescribed to 
the amount of two or three drachms in a gill of warm, sweet- 
ened barley-water, three or four times in the day, will prove 
grateful to the patient, and will allay any existing febrile 
action. Quietude and a bland diet should be enjoined. These 
simple measures comprise about all the therapeutics which the 
case will require at this stage, and will constitute the best 
preparatory steps to any subsequent treatment which the con- 
dition of the individual may demand. 

Should the eruption affect a chronic type, the sulphuret of 
potash bath will be found beneficial, in conjunction with the 
moderate internal employment of mercury. When the papules 
occupy the face, the patient is always anxious to be rid of them 
from that locality, and he will not be content unless some top- 
ical means are prescribed for this purpose. The following 
ointment may be employed at bedtime : — 

X R. Hydrargyri Deuto-Iodidi, gr. j. 

Pulveris Camphone, gr. viij. 

Unguenti Rosarum, § iss. M. 

A small quantity is to be rubbed upon the diseased patches. 

* The following are the results obtained from an analysis of the Congress 
water, as reported by Sir Humphrey Davy and Professor Faraday : — 

R. Chloride of Sodium, 385.44 grs. 

Hydriodate of Soda, 4.02 " 

Carbonate of Lime, 116.00 *• 

Carbonate of Magnesia, ........ 56.80 " 

Oxide of Iron, 64 " 

Carbonate of Soda, 56 « 

Hydro Bromate of Potash, a trace, .... 00 " 

Solid Contents in a gallon, 563.46 « 



316 GONORRHOEA AND SYPHILIS. 

If it produce much smarting, the proportion of the deuto- 
iodide must be lessened, and its application repeated every other 
night only. A moderately stimulating impression on the skin 
is all that is requisite with a view to accomplish the absorption 
of the papules. The iodide of sulphur ointment is sometimes 
an effective local remedy in these cases. 

«• Sulphuris Iodidi, Bj. 

Pulveris Camphorae, gr. vj. 

Olei Bergamotae, 

tl Lavandulae, aa, ^ . . . . gtt. v. 

Unguenti Rosarum, § j. M. 

This preparation can be rubbed upon the papules every 
night. A drachm of the iodide of sulphur to two ounces of 
unguent may be prescribed, if it is not to be employed upon 
the face. 

The tar-ointment has been found beneficial. ' Mr. Acton ad- 
vises that the patient rub the affected parts daily with it, and 
recommends that he do not change his linen. By so doing he 
lives in an atmosphere of tar. In hospital practice, such a 
course can be pursued without difficulty, but with private 
patients it would not be convenient. 

Where the pimples show a disposition to soften and to yield 
a moderate discharge, or to degenerate into small ulcers, I 
have generally found the subjoined formula answer the desired 
purpose. Should the disease be situated upon the face, the 
application can be made without annoyance to the olfactories ; 
whereas the iodide of sulphur and the tar-ointment are not 
agreeable. 

R. Olei Bergamotae, gtt. v. 

Plumbi Acetatis, 9j. 

Unguenti Hydrargyri Nitratis, § ss. 

Cetacei, gj. M. 

Fumigations. — If the eruption assume an obstinate dispo- 
sition, cinnabar fumigations will be of service. Mr. Langston 
Parker has had large experience in the use of several kinds 
of mercurial fumigations, in the management of syphilitic 
affections, both primary and secondary ; and his testimony in 



PAPULAR ERUPTIONS. 317 

their favor is entitled to consideration. His plan is to have 
the patient seated, naked, in a chair or box, with the head and 
face free, as in a common sulphur-fume bath. The mercury is 
volatilized from a tin plate by the heat of a large spirit lamp ; 
at the same time a current of steam is conducted into the 
apparatus. The person remains in the box twenty or thirty 
minutes. The bath may be repeated every second or third day. 
The treatment is not attended with any accidents, such as 
diarrhoea or salivation, and is as certain and as little hurtful 
as any remedial course can possibly be. Even in primary 
phagedenic sores Mr. Parker does not hesitate to employ these 
fumigations. In regard to the merits of his practice with mer- 
curial fumigations, in ordinary instances of secondary affections, 
there can be no doubt ; but in cases of phagedenic ulcers, at 
any stage of the venereal disease, I do not incline to advocate 
the administration of mercury in any form, manner, or quan- 
tity To me it seems to be a matter of doubt how the salutary 
influence of moist mercurial vapor is produced. Does the good 
effect ensue in virtue of the absorption of the exceedingly 
minute portion of mercury which is taken into the circulation 
through the cutaneous vessels, or is the benefit of the bath 
due to the amount of perspiration which the process excites ? 
Of the entire volume of mercurial vapor generated and diffused 
through the whole area of the box which the individual is sup- 
posed to occupy, but a fractional part is deposited on his person ; 
and it appears not improbable that the aqueous vapor and the 
fluid of perspiration must necessarily tend to hinder the mer- 
curial substance from gaining free access to the interior of the 
system. And therefore the query suggests itself, is it the 
mineral agent that goes into the animal economy, or the 
\venereal poison that goes out through the medium of cutaneous 
x exhalation, that confers the benefit ? I am led to these remarks 
because I have witnessed gratifying results from the protracted 
x use of sulphur-fume baths, combined with aqueous vapor, or with 
^dry heat, at a temperature of one hundred to one hundred and x 
ten degrees. The simple, unmedicated vapor-bath, administered 
to persons suffering not only from papular but from various other 
forms of cutaneous eruptions, exerts a highly beneficial in-'-" 
fluence. The stimulating and tonic action of the vapor of 
sulphur, combined with heat and moisture, agrees, I am certain, 
27* 



318 GONORRHCEA AND SYPHILIS. 

with indolent sores and ulcerated surfaces generally, whether 
venereal or not ; and the use of such baths can hardly ever be 
ill-timed, provided the individual has sufficient vigor to go 
through the process without fatigue. In purely papular or 
squamous affections, the remedial agency of the bath is scarcely 
less remarkable. But to secure its best effects, a high, moist 
temperature is requisite, in order to induce a copious perspi- 
ration for an hour or two every day, or every other day, as the 
physical condition of the patient may be. If, in the administra- 
tion of the bath, any circumstance should transpire to prevent 
free perspiration, little or no benefit will be realized from its 
employment, however it may be medicated, whether with 

^sulphur or any mercurial preparation. In hundreds of in- 
stances I have tested the value of the sulphur-fume bath and 
the simple vapor-bath. As curative means of decided efficacy, 
when employed as auxiliary to internal remedies, they can be 
administered in nearly all cases where the patient is not labor- 
ing under any acute or febrile symptoms. The practitioner will 
find them a great help in restoring and maintaining the healthy 
functions of the whole cutaneous surface, and thus conducing to 
the cure of the local disease. The same is true in regard to the 

^artificial sulphureous water-bath, with gelatine dissolved in it. 
Cold sea-bathing, in relation to which patients often make 
inquiries, is seldom admissible. Warm sea-baths, on the con- 
trary, generally promote the improvement of the syphilitic 
invalid. 

I am inclined to the belief that nearly or quite all the benefits 
attributed to mercurial fumigations can, in a majority of cases, 
be realized from the use of either of the other baths that have 
been alluded to. Before dismissing this subject, I must, in 
justice to Mr. Parker, insert a few particulars touching the 
method of employing the mercurial vapor-baths, to which I have 
no objections to offer. If the circumstances of the patient will 
permit their use, they can be prescribed as a safe means of 
ameliorating or curing various consecutive symptoms. "The 
patient is placed on a chair, and covered with an oiled cloth, 
lined with flannel, which is supported with a proper framework. 
Under the chair are placed a copper bath, containing water, and 
a metal plate, on which is put from one to three drachms of the 
bi-sulphuret of mercury, or the same quantity of the gray oxide 



PAPULAR ERUPTIONS. 319 

or the binoxide. Under each of these, a spirit lamp. The 
patient is thus exposed to the influence of three agents, — heated 
air, common steam, and the vapor of mercury, — which is thus 
applied to the whole surface of the body in a moist state. After 
the patient has remained in the bath from five to ten minutes, 
perspiration generally commences, and by the end of twenty or 
thirty minutes, beyond which I do not prolong the bath, it is 
generally excessive. The lamps are now removed, and the tem- 
perature gradually allowed to sink. When the patient has be- 
come moderately cool, the coverings are removed, and the body 
rubbed dry ; the patient is suffered to repose in an arm-chair for 
a short time, during which he drinks a cup of warm decoction 
of guaiacum and sarsaparilla." 

The use of the dilute nitric acid will be attended with favor- 
able effects. In all stages of the complaint it will be found 
serviceable, but particularly so in the chronic ; and it may be 
administered for several weeks in succession, according to the 
annexed formula : — 

R. Acidi Nitrici Diluti, gtt. xxx. 

Syrupi Aurantii, § ij, 

Decoctionis Saponarise, § xij. 

M. The above is sufficient for one day. 

In the syphilitic ward of the Royal Free Hospital, London, 
Dr. Marsden has, for more than twenty years, treated secondary 
eruptions by the administration of stomachic and tonic remedies 
and good diet, conjoined with the following : — 

R. Antimonii Sulphureti, 

Potassae Nitratis, aa, ^v. 

Sulphuris Sublimati, § iiss. M. 

Of this powder, the dose is thirty-five grains, night and morn- 
ing, in syrup or molasses. The London Lancet * states that this 
plan of treatment has been pursued in thousands of cases at the 
above charity, and the most gratifying results have been ob- 
tained. The medicine is to be persevered in for some weeks 
after the cutaneous affection has died away. I have made only 

* Of June 27, 1857. 



320 GONORRHOEA AND SYPHILIS. 

one fair trial with this remedy. The patient was a married 
woman, twenty-nine years old. She had had syphilitic lichen 
on the face, body, and extremities, seven weeks before she ap- 
plied to me. The above powder was the only remedy prescribed. 
The eruption disappeared in six weeks, and did not return. The 
powder was continued in reduced quantities for six weeks after- 
wards. The patient resided in the country at the time, lived 
well, and had the benefit of wholesome air. Her general health 
had not suffered from syphilis. 

In cases of peculiar obstinacy, which resist the action of the 
foregoing medicines, the bichloride of mercury, to the amount 
of one-tenth of a grain twice a day, should be prescribed in con- 
junction with tonics. 

For the purpose of presenting the mode of treatment more in 
detail, and at the same time bringing forward an instance to 
show that the same venereal eruption may have a variety of 
color in different regions, I transcribe from my note-book the 
following case. It will be seen that it offers one or two other 
points of interest; the first is, the lightness of the primary 
disease. The patient had chancre, but no inguinal enlargement 
that ever attracted his attention. In the second place, there was 
an uncommonly long interval between the cure of the original 
accident and the manifestation of constitutional infection ; and, 
lastly, the total absence of the copper color upon the face, and 
its development upon the lower extremities. 

October 26. — N. H., a young medical gentleman, consulted 
me for an eruption, which appeared upon the limbs and else- 
where, about eight months ago. It came upon the legs first. 
The malady on the face is now a well-defined lichen ; is not 
blended with any other affection, nor is it modified by any local 
applications, for none have been used. The face has the appear- 
ance of being slightly freckled ; that is, very small, yellow spots, 
with their outlines not well marked, are scattered over the fore- 
head and cheeks, where the papules are most abundant. The 
pimples about the nose are farther advanced than the rest, and 
are covered upon the summit with an epidermic scale. They 
are all distinct, and are elevated very perceptibly above the 
adjacent integument, but are destitute of the coppery hue. The 
palms of the hands are dotted over with the same eruption. 
Here the papules appeared subsequently to those on the face. 



PAPULAR ERUPTIONS. 321 

Those on the palms are larger than the others ; are perfectly 
hard under the epidermis, which is somewhat broken, and every 
five or six days is cast off in small, micaceous exfoliations. 
The integument here is also free from any coppery tinge. 
The hands present an appearance similar to that seen in the 
commencement of psoriasis palmaris. The arms are slightly 
implicated ; but neither is there here any cupreous hue of the 
surface. The legs were next examined. On these the disease 
first displayed itself, and the general aspect of the integument 
here was decidedly of that dirty, boiled-ham color, which, when 
present, is so justly regarded as almost unequivocal evidence 
that its peculiarity is due to a specific cause. Along the belly 
of the gastrocnemii muscles, and farther downwards, were some 
eight or ten round, deep ulcerations, which had penetrated 
through the derma and cellular tissue; some of them were 
covered with thick brown crusts (ecthyma), below which, on 
pressure, a small deposit of fluid could be detected. Other 
pustules or sores were less protected by scabs, and yielded 
a foul sanious discharge, perhaps some half-dozen drops from 
each in the course of the day. None of the sores were larger 
than a dime, and were all unprotected by any dressing or 
covering except the trowsers. They had been in nearly the 
same condition for several months ; so said the patient. Some 
of the papules on the legs retained their original, frank, liche- 
noid character ; but the greater portion of them had grown 
into good-sized tubercles, or had advanced still farther and 
had become tubercula ulcerantia. The young man was pale 
and thin ; he stated that his flesh and strength had of late 
greatly diminished ; he could walk but a short distance with- 
out fatigue and being obliged to rest ; he complained of 
dyspepsia and constipation ; he consumed large quantities of 
tobacco both in chewing and smoking ; sat up late at night, 
and rose at a corresponding late hour in the morning. He took 
but two meals during the twenty-four hours. There was an 
unnatural sound in his voice, as if the calibre of the air-pas- 
sages were obstructed by tenacious mucus, which gave a hoarse 
rale in the upper part of the trachea when he spoke. The 
fauces were swollen and deeply reddened. The patient re- 
marked that he had for several months been troubled with what 
he supposed was bronchitis. The right testicle was enlarged 



322 GONORRH(EA AND SYPHILIS. 

and at times painful. I had no particular acquaintance with 
this individual, and knew nothing of his previous habits ; but 
from the evidence presented, I could not entertain any doubt as 
regarded the specific nature of his symptoms. Our interview 
was here interrupted, and I did not see him again until 

November 1th. — N. H. called and desired my opinion of his 
case. In return, he was requested to give his own. He re- 
plied that he considered his complaint to be scrofula. I stated 
that my belief was that he had constitutional syphilis. He re- 
marked that this was impossible ; but as I adhered to my po- 
sition, he acknowledged that six years previously he had a 
small chancre, which was cured in a few days, and that he had 
not been ill for a day from the time it healed to the time when 
the eruption appeared upon his legs. He took no mercury for 
the chancre. He was surprised at my diagnosis, and it was 
some time before he acquiesced in it ; he however yielded with 
praiseworthy accommodation of mind. He had great confi- 
dence in the power of mercury to cure all forms of venereal 
symptoms, and requested that it might constitute a leading 
feature in the remedial administration, with which the treat- 
ment should commence. To this I saw no objection, and the 
following course was adopted : — 

R. Hydrargyri Chloridi Corrosivi, 

Ammonias Muriatis, au, ' gr. viij. 

M. ft. pil. No. lxiv. 

Dose. — One pill morning and evening, directly after eating. 

Of the solution of tartrate of iron and potassium, according to 
the formula already given, he took two drachms three times a 
day ; a warm bath every other night. 

As an external application to the face, he used, partly at his 
own suggestion, the following preparation : — 

M« Sulphuris Iodidi, Bij. 

Pulveris Camphoree, gr. v. 

Olei Bergamotse, gtt. vj. 

Unguenti Rosarum, • §j. M. 

The patient was advised to revolutionize his habits ; that is, 
to retire to bed at a more seasonable hour ; to rise early ; to 
take three meals a day, instead of two, and at regular hours, 



PAPULAR ERUPTIONS. 323 

like other people ; to have a generous diet, and to abstain from 
tobacco : all which he promised to do. 

The above ferro-mercurial course was continued for about 
three months. In two weeks an amendment in the constitu- 
tional condition of the young man was quite apparent. Pie 
had a more vigorous appetite and better digestion ; his strength 
improved, and he began to gain in flesh. The cutaneous dis- 
ease did not change for the better until the third week from 
the commencement of the treatment. On two or three occa- 
sions the gums became slightly tender. The pills were accord- 
ingly intermitted for five or six days, and then resumed. He 
continued his avocations most of the time as usual. Fortu- 
nately, no appearance of the skin upon the face or hands be- 
trayed any specific coloration arising from the disease. The 
eruption on the palms disappeared first, then that on the arms, 
and lastly that on the lower limbs. On the latter the charac- 
teristic copper-colored stains remained for a long period, but 
finally faded away satisfactorily. The unavoidable exposure of 
the patient to all states of weather during the winter months 
was calculated to retard the removal of the papules and tuber- 
cles from the face ; and it was not until the mild weather of the 
following spring, that the integument of this unprotected region 
was restored to its normal condition. The orchitis was not very 
troublesome. It would continue for a week or two, and then 
subside under the influence of moderate doses of the iodide of 
potassium, rest, and a suspensory bandage. 

A few words more relative to topical applications to syphi- 
litic lichenoid eruptions. If they assume a chronic character, 
I generally select the iodide of sulphur ointment, as answer- 
ing all the purposes to be gained by the employment of greasy 
substances, — a class of remedies, which we are to avoid if we 
can, but which we are glad on some occasions to call to our 
aid. 

Where the eruption is slight, the subsulphate of mercury will 
frequently answer every desirable end, and will be more agree- 
able to the patient than the iodide of sulphur. 

R. Hydrargyri Sulphatis Flavi, 9j. 

Unguenti Rosarum, § j. M. 

While applying any of the ointments, the utmost care should 



324 GONORRHOEA AND SYPHILIS. 

be observed to keep the diseased surface in a cleanly state by 
the use of warm bran-water every day before the inunction. 
. Stimulating lotions will frequently exert a favorable influence 
upon the papules, if applied in the early stage and before their 
transition into the larger prominences, which are, strictly speak- 
ing, tubercular. The annexed prescription is one of the best : — 

R. Hydrargyri Chloridi Corrosivi, gr. xij. 

Aquae Colognae, 

Spiritus Rectificati, aa, 5j. 

Aquae Fontanse, § viij. M. 

A small quantity is to be dabbed upon the papules three or four times in the 
day. 

The nitro-muriatic acid, properly diluted, makes a very excel- 
lent application. It will be borne, without complaint, of the 
following strength, and will in many instances promote the dis- 
persion of the papules : — 

R. Acidi Nitrici, 

" Muriatici, aa, . . . . . 5j- 

Aquae Fontanae, § xvj. M. 

Lotion. — To be used two or three times daily. 

The ointments and lotions above mentioned are all about on 
a par with each other as to the resolvent power which they 
display ; and if the eruption should occupy any part of the face, 
the patient will not be content unless some of them are em- 
ployed. 



CHAPTER XXIX. 

SQUAMOUS SYPHILITIC ERUPTIONS. 

These constitute a very common variety of venereal affec- 
tions. They are met with in patients, in whom the existence 
of any such taint would scarcely be suspected. In young sub- 
jects they are sometimes seen as an ignoble inheritance. Mr. 
Hunt, a distinguished dermatologist of London, states it as 
his opinion that a large portion of squamous diseases belongs to 
this special category. The non-mercurial treatment of the 
primary syphilitic lesion, which was somewhat the fashion of 
the times a few years ago — more so, at least, than at the present 
day — has probably multiplied the cases of hereditary syphilis 
to an extent of which practitioners generally are not aware. 
The skin of young children seems to be more frequently the 
play-ground upon which this malady delights to revel in its 
secondary form, rather than to dwell among the other tissues. 
But the squamous affections are also seen in persons of maturer 
growth ; and the great difficulty is to distinguish between those 
that are venereal and those that are not. 

The most salient features of the squamous affection, whether 
we call it syphilitic psoriasis or syphilitic lepra, are the forma- 
tion of dry, thin, dark-grayish laminae or scales, reposing upon 
circular patches of dingy red skin. The scales differ entirely 
from the white, silvery hue of lepra vulgaris or ordinary psori- 
asis. The diseased discs are considerably raised and isolated, 
rather than confluent, and of a copper color. This is the rule 
in relation to color, although, as in other stages and forms of 
venereal eruptions, we must admit that there are exceptions 
to this law, in its application to the squamous eruptions. 

Mr. Green gives a good description of this complaint in the 
following quotation: "The squamous forms of syphilide are 
generally so perfectly characterized by the coppery and some- 
times nearly black color of the eruption, by the soft, smooth 

28 (325) 



326 GONORRHOEA AND SYPHILIS. 

surface presented by the patches when freed from squamae, and 
by the flimsiness and scantiness of their scales, contrasted with 
the abundant formation and strength of the epidermic laminae 
in simple lepra and psoriasis, that there is no risk whatever of 
confounding the disease arising from specific causes, with those 
which invade at least under unknoicn influences." 

There are other ways and circumstances by which syphilitic 
psoriasis or lepra may be distinguished from that which is non- 
venereal. In the former variety the patches or discs usually 
occupy less surface than in the latter ; they do not generally 
show themselves around the elbow and knee joints, as is the case 
with simple psoriasis ; and if the eruption has been of long 
duration it acquires a very dark color (psoriasis nigricans) ; the 
scales are thinner and the complaint yields almost invariably to 
the moderate use of mercury. 

Mr. Burgess, who is usually good authority, informs us that 
the characteristic color is always to be found ; for, no matter 
how small the patches may be, they are never covered entirely 
by the epidermic scale. In the main this statement is without 
doubt correct ; and yet, if the young practitioner were to 
take it as an infallible guide, he would in some cases be very 
likely to err in judgment. It seems to me that the idea in re- 
gard to color, introduced as a matter of such uniform con- 
stancy in the venereal squamous affections, has not its founda- 
tion in the pathological state of the skin any more than it has 
in the other syphilodermata. In this connection, I submit the 
following case, which affords a striking illustration of the liabil- 
ity to blunder to which the wisest men are exposed when under 
the guidance of the old but false doctrine here alluded to, and 
which was so long held in almost sacred repute. 

Case. — I once knew an error in diagnosis to be committed 
by an eminent surgeon, in one of our chief cities, in reference 
to this particular type of syphiloderma. He gave his written 
opinion that a certain case was not venereal because the pecu- 
liar discoloration did not exist. The patient came to Boston. 
It was in September, 18 — . He was twenty-nine years of age. 
On the recommendation of Dr. Wm. J. Dale, he called upon 
me, in company with his father, who had formerly been a prac- 
tising physician, but had become a wealthy farmer. The young 




Annular Crustaceous Eruption 



SQUAMOUS SYPHILITIC ERUPTIONS. 327 

man was married to a healthy woman, who had suffered two 
miscarriages. He was of diminutive stature, emaciated and 
feeble ; could scarcely walk a hundred rods ; his appetite was 
miserable ; he had much trouble from constipation ; his tongue 
was coated ; the pulse one hundred ; and there was extreme 
pallor of countenance. There were several squamous blotches 
on the face, varying in size from that of a ten-cent piece to 
twice that bigness, and slightly elevated above the adjacent 
sound skin. Some of them had healed from the centre and 
presented an annulate figure. Large portions of integument 
covering the body and extremities were occupied by the erup- 
tion in different stages of development. The most singular 
and interesting specimens consisted of annular, tuberculo-crus- 
taceous patches, of various dimensions. One of these, situated 
on the right fore-arm, embraced within its circuit nearly a third 
part of the integument of its dorsal aspect. It was produced 
by the union of numerous groups of tubercles, which had par- 
tially softened on their summits, and yielded a very scanty puru- 
lent exudation, — the latter having desiccated into a thick, dark 
incrustation. The area included within the ring had all 
formerly been the seat of the same deranged action, which, as 
the eruption healed, had a centrifugal tendency ; that is, as it 
got well in the central part, new tubercles would appear, just 
outside the borders of the cicatrix, which widened in every di- 
rection in nearly equal ratio, and which now presented a reddish 
brown or vinous tint. (Plate III.) 

On the back were five or six morbid patches similar to the 
one represented in the plate. The friction of the clothing and 
that arising from locomotion created in some of the diseased 
localities considerable irritation and discomfort, with a copious 
oozing of sanio-purulent matter. On the right buttock there 
was one large patch, which interfered with any attempt at 
walking and with the usual sitting posture. The legs and arms 
were thickly covered with eruption, which, in most instances, 
took the annulate form, and varied in size from half an inch 
to thrice that diameter, squamous in some spots, in others 
tuberculo-crustaceous. On the entire surface there were some 
seventy or eighty of these sores. They produced no itching, 
but gave rise to a most offensive exhalation. The patient had 
neglected to bathe for a long time. The sebaceous apparatus 



328 GONORRHOEA AND SYPHILIS. 

was in a state of atrophy for want of nutrition ; the whole of 
the integument not actually implicated in the complaint was 
covered with dry, rough epidermis and other accumulated 
exuviae. At times, during inclement winter weather, there had 
been sore throat to a moderate degree. The patient was ex- 
tremely feeble and desponding, and was a spectacle of 'great 
wretchedness. He denied ever having had primary syphilis. 
His father remarked that he had consulted some of the most 
eminent surgeons and physicians in the United States, both 
at the North and the South, and that the subject had often 
been discussed, and that no medical man who had examined 
his son regarded his case as venereal ; an idea which the father 
seemed to endorse. I obtained a private interview on the fol- 
lowing day with the son. On this occasion he acknowledged, 
after a few evasions, that he contracted a gonorrhoea in New 
York two years previous to the appearance of the cutaneous 
affection. The case was now relieved of the thin veil that 
overhung it. The chain of evidence was strong and complete, 
and my judgment and my course were unembarrassed. The 
father, who was waiting in another apartment, was invited into 
the consulting room. I communicated to the parties my opinion 
that the malady was constitutional syphilis, having its origin, 
probably, in urethral chancre. Great dissatisfaction was mani- 
fested by father and son, and the written opinion of the emi- 
nent surgeon above referred to was presented as antagonistic 
to mine. I replied that the case was to me as clear as the light 
of day, and that no names or documents would induce me to 
change my position. After wasting about two hours in fruitless 
debate, it was agreed that Dr. Dale and Dr. J. Mason Warren 
should be called in consultation ; and that, if their diagnosis 
harmonized with mine, the decision should be considered cor- 
rect and final, and that I should have the professional care 
of the patient. The first part of this arrangement was con- 
summated in a few hours ; and after a thorough examination of 
the young man, the two consulting gentlemen corroborated my 
opinion. Next morning the father and son took the cars for the 
purpose of again visiting the aforesaid eminent surgeon, and of ' 
reporting to him our views in regard to the case. 

In communicating our decision to this surgeon, the patient, 
in accordance with my advice, acknowledged that he had for- 



SQUAMOUS SYPHILITIC ERUPTIONS. 329 

merly been exposed to the infection of primary syphilis, etc. 
The surgeon, perceiving at once the whole merits of the ques- 
tion, exclaimed, " Primary syphilis ! primary syphilis ! you did 
not tell me that; the Boston doctors are right." The last 
remains of the cobweb were now swept from the father's mind. 
He returned to Boston, and committed the son to my care, and 
a course of treatment was at once inaugurated. It embraced a 
period of two years, at the expiration of which it was brought 
to a happy termination. A brief resume of what was done is 
all that I propose to give. For a long time tonics constituted 
the basis of nearly all the internal remedies ; and prominent 
among these was the potassio-tartrate of iron, at the rate of one 
drachm per diem, in an infusion of quassia. The appetite was 
soon quickened, the digestion improved, and an increase of flesh 
became apparent in a few weeks. By careful attention to diet, 
particularly the free use of fruits, such as apples, pears, or- 
anges, and grapes, the normal function of the bowels was grad- 
ually restored, and was easily maintained. By the use of the 
sponge and slightly chlorinated water, the faithful wife kept 
the poor victim in a cleanly condition, until he was able to 
endure warm-water baths, which were sometimes impregnated 
with sulphuret of potash, and sometimes unmedicated. As 
soon as he had gained a fair amount of strength, the pulse 
having acquired considerable volume, and the capillary circula- 
tion being well established, as shown by warmth of the extremi- 
ties, the use of the bichloride of mercury, in pills, was added 
as auxiliary to the ferruginous solution. The daily quantity 
of the oxymuriate ranged from one-eighth to one-fourth of a 
grain, care being taken not to disturb the normal condition of 
the mucous membrane or salivary apparatus. The time for the 
continuous employment of the last remedy varied from four to 
six weeks, generally followed by an intermission of two or 
three weeks. Given in this guarded manner, it appeared to 
act as a valuable therapeutic adjunct to the other constitutional 
means, and not the slightest inconvenience was experienced 
from it. From the moment the treatment was instituted to its 
close no retrocession of symptoms took place. The progress 
towards a cure was indeed slow ; but it held the even tenor of 
its way, until all evidence of the syphilitic contamination dis- 
appeared, so far as relates to actual symptoms. The patient, 
28* 



330 GONORRHCEA AND SYPHILIS. 

who, from the beginning, carried out the prescribed course in 
its minutest details, has enjoyed comfortable health for several 
years. 

Besides the remedies above mentioned, other suitable medi- 
cines were employed, such as dilute nitric acid, large libations 
of the compound decoction of sarsaparilla, decoction of yellow 
dock-root, Congress Spring water at the fountain, the tincture 
of the muriate of iron, the citrate of iron and quinine, cod- 
liver oil, acetate of ammonia, and small quantities of the iodide 
of potassium, together with the use of various topical appli- 
ances, already sufficiently alluded to in previous pages. Nor 
was the benefit resulting from a salubrious atmosphere and 
agreeable exercise forgotten. The patient took board a short 
distance from the city, and, as soon and as fast as his strength 
would permit, he was daily on the wing, making short excur- 
sions with his friends, visiting fashionable watering-places and 
other notable localities. 

In many cases the syphilodermata have their distinctive 
characters well marked ; and the eye that is familiar with them 
can recognize their signification almost as readily as one can 
tell the hour of the day by looking at the face of a watch. On 
the contrary, there are other cases, in which the eye is not 
sufficient. The mind needs to consider the ensemble of the 
symptoms collectively, whether revealed to the organ of vision, 
or depending upon the general condition of the patient, or gath- 
ered from his past history. All the sources of information 
should be explored. The entire facts in the case are as essen- 
tial to the practitioner as they are to a judge in deciding a 
matter of jurisprudence. 

When we are unable, with all the assistance we can com- 
mand, to arrive at a clear and satisfactory diagnosis, we can 
sometimes resort to mercury as a test. The ground on which 
this recommendation rests is this : if the eruption be venereal, 
the medicine will be likely to relieve it ; if not venereal, the 
patient will be liable to get worse. The medical attendant may 
be so situated with respect to the individual that he cannot 
exchange words upon the topic with safety or propriety. Such 
circumstances do now and then happen. Upon the subject of 
syphilis the physician is bound to keep silence. In suspicious 



SQUAMOUS SYPHILITIC ERUPTIONS 331 

instances, the usual avenues to the truth being unavailable, 
mercury may be properly summoned as a witness, provided the 
general health and the condition of the person will warrant the 
experiment, and provided, also, that other means have been 
tried to no good purpose. On the other hand, it must be 
acknowledged that cases exist in which the mineral in question, 
even if administered till the system be absolutely saturated with 
it, would afford no clew to the real character of the complaint. 
It is not every syphilitic subject who can tolerate the action of 
mercury in any form or quantity. 

The syphilitic pimple, which, in the elementary form, is a 
papule or tubercle, may terminate in a squamous disease, ex- 
hibiting repeated desquamation of the epiderma, in thin, flimsy 
scales. Sometimes the syphilitic spots are evolved in the form 
of squamae at the beginning of their appearance. They occa- 
sionally show a disposition to yield a very little purulent dis- 
charge ; but I am inclined to believe that in a majority of in- 
stances, regarded as squamous, the lichenoid papule or the 
tubercle precedes the squama, the latter condition being simply 
the secondary stage of the eruption. 

The true squamous blotches belong either to psoriasis or 
lepra. They present themselves as circular discs, perceptibly 
elevated above the adjacent skin, are of different sizes, from 
the fourth of an inch to an inch in diameter, rarely accom- 
panied by any moisture from the morbid surface, and causing 
no inconvenience from pruritus ; differing in this last particu- 
lar from ordinary, non-specific eruptions of the same order, 
which are always a source of irritation and annoyance to the 
individual, even when only a very limited portion of skin is 
implicated. 

The terms, syphilitic psoriasis and syphilitic lepra, as at 
present understood by dermatologists, are applied to one and 
the same disease. They differ, it is true, in the form of the 
patches which they exhibit, but not otherwise. The particular 
portions most commonly occupied are the scalp, the anterior 
surface of the body, the palms of the hands, and the soles of 
the feet. When the two last named are involved in these 
chronic, squamous inflammations of the derma, the scales are 
remarkably thick, corneous, dry, and brittle. The syphilitic 
squamae are to be regarded as of an inflammatory nature, 



332 GONORRHOEA AND SYPHILIS. 

although the inflammation is of a low, subacute type. The 
usual characters of inflammatory action, such as heat, pain, 
smarting, burning, throbbing, etc., are almost entirely absent. 
The same is substantially true of other syphilodermata. As we 
have already seen, one of the most remarkable peculiarities of 
them all is a deficient sensibility of the part involved in the 
disease, as if the cutaneous nervous substance were dead, or 
had nearly lost its functional energy. And perhaps this ner- 
vous defection gives rise to other singular features that apper- 
tain to venereal eruptions. 

Sometimes the squamous affection exists on the palms of the 
hands as the only manifestation of constitutional taint, and 
shows a disposition to extend in every direction from a central 
point, thus presenting an annulate figure. It is called psoriasis 
palmaris centrifug-a, or erythema palmare annulatum syphiliti- 
cum. Distinct and well-marked tubercles are often found asso- 
ciated with the squamae in different parts of the affected area. 
Occasionally the disorder is developed on the back of the hands, 
and the central portion of the morbid surface presents a dark, 
livid hue for a long period, in consequence of enfeebled capil- 
lary action ; and the scales which are detached from time to 
time are also of a very dark color, nearly black ; but, as the 
process of cure advances towards completion, and the constitu- 
tional vigor waxes stronger, the integument resumes, by slow 
degrees, its natural properties, and the abnormal color fades 
away. The malady described as lepra nigricans is probably 
nothing more than this lepra syphilitica, characterized by dark, 
fuliginous squamae. The blotches assume various tortuous 
appearances or forms, which are modifications of a circle, or 
segments of a circle. 

In some instances the scaly eruption is accompanied by other 
consecutive symptoms. The mucous membrane of the nasal 
apertures and of the external auditory meatus, the eyelids, and 
mouth will exhibit marks of depraved action in the form of 
small pustules, excoriations, abrasions, or ulcers. Now and 
then leprous squamae are seen on the face, or on the superior 
portion of the trunk, associated with tubercles on the arms, 
while ulcerations of various extent occupy the inferior extremi- 
ties. These several coexisting phenomena indicate a serious 
impairment of the system, and are rarely present unless the 



SQUAMOUS SYPHILITIC ERUPTIONS. 333 

patient has struggled for a very long period against the venereal 
poison. When the squama? appear upon the scalp, the hair 
usually falls out, and it can seldom be restored to any great 
extent. In non-specific squamous eruptions the pilous appa- 
ratus remains intact, or nearly so. 

TREATMENT OF SQUAMOUS ERUPTIONS. 

The constitutional treatment with mercury, recommended 
where syphilitic lichen affects a chronic type, is equally appro- 
priate in squamous diseases of specific origin. As they are sel- 
dom accompanied by inflammatory action of any great amount, 
either local or constitutional, antiphlogistics are not required. 
These squama? cannot, in fact, be subdued by such energetic 
measures. Mercurials may be administered with a somewhat 
bolder hand than would be allowable in a lichenoid syphilo- 
derma. The gums, should be made, not absolutely sore, but 
quite tender, and the medicine be graduated in quantity so as 
to keep the gums in this condition until the cutaneous disease 
shows a disposition to decline. If the system be properly sus- 
tained by a full, nutritious diet, and the appetite encouraged by 
the administration of ferruginous tonics, or by quinine, or the 
infusion of quassia, the patient has nothing to fear from a some- 
what protracted use of mercury. Its depressing influence can, 
in nearly all instances, be prevented, if the physician allow, in 
connection with it, a generous mode of living. To prescribe 
mercurial agents, and at the same time restrict the patient to a 
poor bill of fare, is, in my opinion, no way to cure him of con- 
stitutional syphilis. 

All the liberality which the digestive apparatus can bear 
should be shown, in order that the system may be raised and 
preserved as near a healthy standard as possible. In my esti- 
mation it is of little avail to maintain a ceaseless warfare against 
the disease, by the employment of potent remedies, while the 
patient is kept on a meagre allowance of food. We might as 
well expect a ship to sail without wind, or a rush to grow with- 
out water, as to expect that syphilis can be subdued by such 
treatment. The squamous eruptions being, like the chronic 
venereal affections generally, of an asthenic character, there is 
a .prevailing tendency to constitutional debility, which we are to 



834 GONORRHOEA AND SYPHILIS. 

guard against. To check this downward inclination most ef- 
fectually, we must sustain the energies of the system by food at 
once nutritious and easy of digestion, and thus confer upon the 
various organs, tissues, and fluids ability to antagonize the in- 
imical principle that is hidden within the physical organization. 
Milk will usually agree with the patient. It comes already 
cooked, and contains such a combination of animal and vegeta* 
ble qualities that no improvement can be made upon it. The 
patient may, at the same time, require a diffusible stimulant 
with it ; and the physician need not hesitate to allow the addi- 
tion of half an ounce or so of the best brandy, or a still larger 
quantity of Sherry or Madeira wine, to half a pint of milk, three 
or four times in the course of the day and night. To endow 
the impoverished and infected blood with more opulent qualities 
is also an end we accomplish by the liberal administration of 
ferruginous medicines ; for it is a point now well established, 
that, by the exhibition of such remedies, the process of hasma- 
tosis in the economy is facilitated, and that, in the normal 
growth and development of the blood, its characteristic corpus- 
cles are augmented numerically ; and hence the therapeutic 
value of chalybeates, whether given in conjunction with mer- 
curials or with the iodide of potassium. 

With a view, also, of restoring the lost tone of the constitu- 
tion, the cod-liver oil may, in many cases, be advantageously 
prescribed in closes of two drachms three times a day, gradually 
increasing the daily quantity to ten or twelve drachms, provided 
it be borne quietly. It is sometimes difficult to reconcile the 
stomach to the presence of the oil, even in the smallest amount. 
But its salutary effects in sharpening the appetite, and promoting 
nutrition, and overcoming in a good degree the cachectic state 
of the system, are well known ; and its claims to our confi- 
dence, in the condition of things we are now considering, can- 
not be doubted. It is usually retained quite well if adminis- 
tered in pale ale, or in the infusion of hops. Its disagreeable 
taste can also be disguised somewhat by the addition of a few 
grains of salt, by the aid of which it is more easily digested. 

Jellified Cod-Liver Oil. — An article bearing this title is 
manufactured by Mr. E. Queru, a practical chemist of New 
York. It has already attained considerable notoriety and 



SQUAMOUS SYPHILITIC ERUPTIONS. • 335 

favor with practitioners, and in all probability is destined to 
become still more popular as a therapeutic agent, especially 
for delicate females, and other individuals who have great re- 
pugnance to the oil. As a medicine its value is equal to that 
of the latter substance, while it possesses the important advan- 
tage of being in a great degree deprived of its nauseous proper- 
ties, and is tolerated by persons who cannot endure the oil. It 
contains eighty-five per cent, of the latter. It can be swallowed, 
without masticating, in a little sweetened water. Used in this 
manner the invalid perceives little or no taste, nor does it dis- 
turb the stomach like the crude oil. 

The jelly will be found most appropriate for those syphilitic 
patients who exhibit a mal-assimilative diathesis and great ema- 
ciation. 

Cod-liver oil has also been converted into a dietetic form by 
Mr. Lebague, a chocolate manufacturer of London.* It is com- 
bined with chocolate in the proportion of four ounces to the 
pound. The cakes are divided into small tablets, each of 
which contains one drachm of the oil. This preparation is 
particularly convenient for children as a valuable dietetic medi- 
cine. The idea of prescribing the oil in this manner originated 
with Professor Wilson, who states that he has found it of great 
service. 

If mercurial preparations are taken in immediate connection 
with the food, a larger quantity can be borne without exciting 
irritation in the alimentary canal than could be on an empty 
stomach. 

Biett advises that the bichloride of mercury be taken in com- 
bination with opium, thus : — 

R. Hydrargyri Chloridi Corrosivi, gr. xij. 

Pulveris Opii, gr. xx. M. 

Ft. pil. No. xxxvj. 

Give one pill every morning, increasing the dose by degrees, 
and discontinuing the medicine, from time to time, in case the 
bowels become too much affected. In his early practice Biett 
gave the preference to the oxymuriate over the other forms of 



* Of No. 10 Little Tichfield Street, St. Marylebone. The chocolate 
be obtained at Metcalf s, Tremont Street, Boston. 



336 GONORRHCEA AND SYPHILIS. 

mercury. Wilson is partial to the bin-iodide, as at first recom- 
mended by Biett, although Biett soon relinquished the bin-iodide 
for the proto-iodide, which is more manageable, and is an elimi- 
native agent of great power. The formula, as preferred by 
Ricord, has already been mentioned. The quantity of this 
salt for ordinary use is from one grain to four grains in the 
twenty-four hours. If opium be given in combination with the 
proto-iodide, the therapeutic qualities of the latter are com- 
pletely neutralized, and therefore it should be prescribed in an 
uncombined form. Biett made this discovery. 

For the purpose of awakening the cutaneous excernent sys- 
tem to increased action, sudorifics are to be prescribed as im- 
portant adjuvants to mercurials. The kidneys are also to be 
brought into active play, and urination encouraged by the em- 
ployment of diuretics. Thus, by the most efficient and at the 
same time the most simple and harmless remedies, the skin 
and kidneys, with their immediate associate organs, can be 
used for any length of time as drains in relieving the economy 
of the poison that pervades it. 

The question often arises, how long is the mercury to be 
continued ? Sir Astley Cooper was wont to say that the 
greatest secret in the treatment of syphilis is knowing when 
to discontinue this remedy. So long as the patient gives evi-. 
dence of improvement under its influence, so long it is to be 
employed ; but circumstances sometimes unexpectedly occur 
which render its further administration impracticable, and we 
are compelled to seek other remedial means as a substitute. In 
such cases the iodide of potassium will frequently prove a 
valuable article. 

In some instances that have long been under mercurial treat- 
ment the disease seems to remain uninfluenced by it, and the 
general condition of the patient is retrograde. His appetite, 
flesh, strength, sleep, and courage, perhaps, have failed him. 
In this condition of things it will be advisable to suspend the 
administration of the mercurial, and to order the potassium, 
which may be given in doses of three or four grains, three 
times a day. 

It may be directed as follows : — 

ft. Potassii Iodidi, 3 ij- 

Extracti Gentianse, q. s. M. 

Ft. pil. No xxx. 



SQUAMOUS SYPHILITIC ERUPTIONS. 337 

Give one pill three times daily. Or the following : — 

R. Potassii Iodidi, 3 iij- 

Syrupi Sarsaparillae, 

Aquas Fontanae, aa, § iiss. M. 

Dose. — One drachm, morning, noon, and night, in a wineglass full of 
cold water, in immediate connection with the meals. 

I have known persons who could not tolerate the iodide, even 
to the amount of only one grain in the day, on account of the 
severe and sudden inflammation which it excited in the skin. 
The subjoined instance is an illustration : — 

A few years since, Dr. J. Mason Warren recommended to my 
care a lady who had suffered for several months from consti- 
tutional syphilis. I took charge of the case, Dr. W. being re- 
tained as consulting surgeon. In the process of treatment a 
crisis arrived when it was judged expedient to try the iodide of 
potassium in small quantities. Within twenty-four hours from 
the time the first dose was taken an erythematous condition of 
the integument of the face, neck, and chest displayed itself; 
and at the expiration of a few days more an abundant lichenoid 
eruption appeared, to the great annoyance and alarm of the 
patient. The medicine was discontinued, and in a short period 
the lichen disappeared. Several weeks subsequent to this acci- 
dent a second attempt was made with the iodide in pills of 
two grains. The patient took a pill at night. The next morn- 
ing the face was thickly dotted over with a minute papular 
eruption. The iodide was abandoned for one month, when a 
third trial was made, and a pill, containing one grain of the 
salt, was used at bedtime. The lichen was produced as on 
former occasions, but with less severity. This is the only 
instance of such peculiar idiosyncrasy that I have witnessed, 
and I was at first incredulous as to its reality.* 

* Dr. Morland has recently had under his care a man who manifested a pe- 
culiar susceptibility as regards the iodide. The patient was thirty-nine years 
of age. The iodide was given in the compound decoction of sarsaparilla. 
Only two grains and a half were taken at a time, twice a day. On the second 
day the patient had so severe a coryza and headache, and was so uncomfort- 
able every way, that Dr. M. was about to suspend the medicine, it seeming 
evidently to be the cause of these symptoms. It was, however, given once on 
the third day, when, almost immediately after its administration, there was so 

29 



338 GONORRHCEA AND SYPHILIS. 

Patients sometimes complain of a painful sensation in the 
throat and at the epigastrium for an hour or two after swal- 
lowing the potassium even in moderate doses. The aversion 
to it has been somewhat frequent in my experience ; and 
occasionally of such a decisive tone that I have been com- 
pelled to abandon its use before a fair trial of its curative 
effects could be made. It has appeared, in some instances, to 
be better borne if made into pills with the extract of gentian, 
than when given in solution ; but I have known individuals to 
complain of a distressed, sinking feeling in the stomach, occa- 
sioned by the pills. In whatever form administered it is apt 
to produce a thick, white coating upon the tongue ; the mouth 
is sometimes exceedingly troubled by the secretion of a ropy 
mucus ; the patient suffers somewhat as from slight ptyalism, 
and a loss of appetite ensues. 

The abnormal condition of the mucous membrane, buccal 
glands, and stomach soon disappears if the potassium be dis- 
continued. Still more serious and noxious pathogenic effects, 
attendant on the employment of this article, are on record. 
It now and then provokes epistaxis. In some persons an acute 
coryza is induced ; and I have known it to occasion swelling 
of the face, — the conjunctiva at the same time being highly 
injected and painful, as a consequence of the peculiar action 
of the medicine. It has been thought to bring out patches 
of purpura upon various portions of the skin. Its influence 
on the general circulation is of a sedative nature, and it dimin- 
ishes the force and number of the arterial pulsations. Some- 
times it excites irritation in the intestinal mucous membrane, 
and a diarrhoea sets in ; at other times what is termed the 
iodic intoxication is observed. This latter condition may be 
known by a disturbance of the involuntary muscular move- 
ments, as spasmodic twitchings ; and even the mental faculties 
are disturbed for a few hours. All these unpleasant accidents, 
however, subside very soon after the discontinuance of the rem- 
edy ; and it is but just to say that they really constitute no 
valid objection to its general use. Some patients, even females, 

great an aggravation of the symptoms mentioned, that he abandoned the use 
of the remedy. In less than twenty-four hours all the disagreeable sensations 
had vanished. 



SQUAMOUS SYPHILITIC ERUPTIONS. 339 

can take two or three drachms of the potassium in the twenty- 
four hours without inconvenience ; and it has been adminis- 
tered to the amount of twelve and sixteen drachms in the day, 
and yet its properties, in these instances, were perfectly in- 
nocuous. 

For the purpose of rendering the medicinal substance in 
question more agreeable and efficient, I have for a year or 
two past been accustomed to combine it with the carbonate 
of ammonia, which is a decided improvement. The impression 
upon the stomach and upon the general sensations of the pa- 
tient is very pleasant. This is the report uniformly rendered 
by those who have made trial of the combination, — which is 
the following : — 

K. ' Ammoniae Carbonatis, 5 iss. 

Potassii Iodidi, 5 iij- 

Syrupi Sarsaparillse Compositi, 

Aqua? Fontanse, aa, § iiss. M. 

The usual portion is one drachm, three or four times daily, 
in a gill of cold water.* 

The extremes as to the dose of the potassium are at a great 
remove from each other. No other remedy of established 
reputation enjoys so wide a range in this respect. What is 
considered a medium quantity, in ordinary cases, is a matter 
quite unsettled among the leading practitioners of the day ; 
and there is no uniformity of opinion as to the class of cases 
in which it should be given, excepting those belonging to the 
tertiary syphilitic period. For the removal of these tertiary 
conditions its curative power is preeminent over all other 
medicines. In some tardy secondary affections I have occa- 
sionally prescribed it with the most satisfactory results. The 
amount which I prefer for long-continued use rarely exceeds 
six or seven grains three times daily. The London surgeons 
are mostly in favor of small quantities, in the belief that from 
these all the benefit will accrue that can be derived from large 
doses. Acton and Ricord employ large doses if small ones 

* An opinion prevails at Guy's Hospital that the efficacy of the potassium is 
very much increased by its union with the ammonia. Vide Medical Times and 
Gazette, 1854, p. 488. 



340 GONORRHOEA AND SYPHILIS. 

do not succeed, and they order it in conjunction with the 
tartrate of iron and potassium. 

In June, 1857, I saw a girl, twenty years of age, then under 
the care of Dr. Salter, for constitutional syphilis, from which 
she had suffered for more than two years. For some months 
she had received no regular medical attention from any quarter, 
and her symptoms, which were both secondary and tertiary, had 
been gradually augmenting in severity. She was anaemic and 
much emaciated. For several weeks Dr. S. directed a moderate 
use of the iodide, together with tonics and a good diet ; but as 
no abiding amendment was perceptible, he increased it to one 
drachm three times a day. This quantity was taken every day 
for four months. The patient experienced no inconvenience 
from the medicine ; on the contrary, she began to convalesce 
very soon and very satisfactorily after commencing with the 
large portions of the potassium, and entirely recovered under 
this treatment, without any return of her symptoms. This is 
the only instance in which I have known the salt to be adminis- 
tered so liberally for so long a period. 

The comparative merits of mercury and the iodide of potas- 
sium seem to have had a fair trial in the hands of Mr. Ormerod, 
at St. Bartholomew's Hospital. In reference to the latter medi- 
cine, the subjoined extract is the concluding paragraph of Mr. 
Ormerod' s report : — 

" The employment of iodine, however, has been attended 
with greater and more uniform success than any other remedy, 
except mercury, which has ever been introduced for the treat- 
ment of venereal diseases. Those affections which yield least 
to mercury, and that condition of health which succeeds to 
long-standing disease, and to the employment of very large 
quantities of mercury, yield to iodine in the most marked and 
decided maimer." The opinion of Willis, as expressed in his 
" Illustrations of Cutaneous Diseases," in regard to the potas- 
sium, is this: "In broken constitutions, where mercury has 
been freely used at some former period, I believe that the 
iodide of potassium deserves all the credit it has obtained ; it 
is an invaluable addition to our materia anti-syphilitica." 

Iodide of Sodium. — This salt can be employed as an anti- 
syphilitic, instead of the iodide of potassium, in cases where 



SQUAMOUS SYPHILITIC ERUPTIONS. 341 

the patient cannot take the latter. It is not disagreeable to the 
taste, and is not followed by unpleasant effects. It may be 
ordered in all instances where the potassium is indicated. The 
daily quantity is from a scruple to two drachms. Dr. Gamber- 
lini, of the Hospital of St. Orsola, Bologna, and Mr. Langston 
Parker, speak in terms of commendation of this remedy as a 
valuable addition to the substances usually employed in the 
cure of the venereal disease. 

The subjoined formula will be found convenient : — 

R. Sodae Iodidi, 5j. 

Syrupi Sarsaparillae Compositi, 

Aquae Fontanae, aa, § iij. M. 

Dose. — One drachm thrice, daily, in a gill of cold water. * 

The liquor potassae has gained a reputation for the cure of 
syphilitic squamous eruptions. It may be administered in 
milk or in an infusion of hops. The dose is one drachm three 
or four times in the day. The dilute nitric acid is also a valu- 
able remedy for many venereal patients. It is well calculated 
to revive the tone of the digestive organs, and is particularly 
indicated after a mercurial course has been pursued for a long 
period. Thirty or forty minims, per diem, in sweetened barley- 
water, may be given for two or three weeks. 

Donovan's solution sometimes proves an efficacious remedy in 
this form of cutaneous affection. It is the liquor hydriodatis 
hydrargyri et arsenici. The dose of this compound solution is 
ten minims three times a day. It should always be taken on a 
full stomach. The following will be found a suitable for- 
mula : — 

R. Liquoris hydriodatis hydrargyri et arsenici, . . . . § j. 

Syrupi Aurantii, § vj. M. 

Give one tea spoonful in half a gill of cold water. 

The mercurial vapor-bath, or the simple vapor-bath, can be 
beneficially employed if its application be practicable. 

*For making the iodide of sodium economically and easily, a formula can be 
found in the American Journal of Pharmacy for 1854, p. 305. 

29* 



CHAPTER XXX. 
TUBERCULAR SYPHILITIC ERUPTIONS. 

These may almost be regarded as a larger growth of the 
mere papules of lichen. In their original size and type, how- 
ever, they are bigger than the minute, shot-like papules of true 
lichen. As elementary cutaneous lesions, they are commonly 
described as indurated lumps developed in the substance of 
the skin. 

The late Mr. Babington believed that they had their origin in 
the sebaceous glands ; and this is partly true. They vary some- 
what in diameter when they first appear, as well as in their 
subsequent progress, according to the number of papillae and 
follicles involved in the inflammatory congestion. They differ, 
also, in prominence. By bearing in mind the manner in which 
the lichenoid eruption is developed, it will not be difficult to 
comprehend the process of growth which results in the for- 
mation we are now to consider. The pimples of lichen often 
advance and swell into veritable tubercles ; and both, that 
is, the lichen and the tubercle, are preceded by a roseolous or 
erythematous condition of the derma. 

The tubercles may be crowned with a scab upon their sum- 
mits when the patient first presents himself for medical aid, or 
they may be without this covering. Many specimens are dry, 
and almost hard to the touch ; others impart a sensation of 
moisture to the finger ; they are often slightly elastic, and yield 
under gentle pressure. At one time they are perfectly indolent, 
and remain for weeks or months without perceptible change. 
At another time they will be transformed with great rapidity into 
sloughing ulcers, and spread over large portions of skin in a 
short period. In feeble and anaemic patients the skin seems, as 
it were, to dissolve and melt away under this morbid process, in 
a manner truly frightful, especially when the disease is seated 
on the forehead, which is one of its favorite localities. Occa- 

(342) 



PL W 




Tubercular Syphilis 



PL V 




bercular Syphili 



TUBERCULAR SYPHILILIC ERUPTIONS. 343 

sionally the tubercles, appearing in small clusters, continue for a 
while distinct and isolated, and afterwards blend at their bases 
by a process of peripheral augmentation which fills up the 
interspaces. Each tubercle has now lost its individuality, and 
the integument appears as if covered with the eruption of 
psoriasis. When a long term of years has intervened between 
a primary chancre and the development of tubercles, the latter 
are apt to prove peculiarly obstinate in their resistance to treat- 
ment. If they appear upon any part of the face, they exhibit a 
brighter red color than when seated upon other districts that are 
protected by the clothing. 

As with the papules of lichen so with syphilitic tubercles, 
there is some variety in their style of distribution ; hence 
Wilson has given the names, tubercula corymbosa, tubercula 
circumscripta, tubercula disseminata, tubercula annulata; and 
when there is a strong pyogenic tendency in the system, and any 
of these varieties are converted into ulcerations, they are termed 
tubercula ulcerantia. These divisions are not entirely nominal. 
They are fully warranted and exemplified by the different modes 
of distribution of tubercular eruptions that are frequently met 
with in the venereal patients; and, considered in a scientific 
light, we cannot but approve of Wilson's classical nomencla- 
ture. [Plates IV., V:] 

A large proportion of tubercles pass into foul, excavated 
ulcers with elevated edges, which, when they heal, leave behind 
them a deeply pitted cicatrix. Sometimes they disappear by 
resolution or absorption, without yielding any discharge ; but 
even then they occasionally imprint a significant, depressed, and 
indelible mark upon the spot they have occupied, although not 
so profound nor so conspicuous as when ulceration has attended 
their destruction. 

Phagedenic syphilitic ulcers, which are formed upon the soft 
parts near the commissure of the lips, upon the cheeks, and 
elsewhere, have their origin in tubercles, which first soften and 
ulcerate at their summits, and subsequently extend in every 
direction. It is not uncommon for several tubercles in the same 
neighborhood to ulcerate simultaneously. These ulcers coalesce, 
spread outwardly, present hard, jagged edges, and pour out a 
thin, dirty, sanious discharge at some points, while at others 
they are covered with dark, firmly adherent incrustations. 



344 GONORRHOEA AND SYPHILIS. 

Another form of ulcer, originating in tubercle, is the serpig- 
inous. In some instances this ulcer is quite superficial, and 
may occupy a large portion of integument without serious detri- 
ment to the general system. It causes quite limited destruction 
of the dermoid tissue ; but creeps along in circles or segments 
of a circle, in spirals and other circumvolutions, the lesion vary- 
ing in width from the eighth to the fourth of an inch, and 
sometimes wandering over an immense tract of skin. It 
appears most frequently on the neck, chest, and back, pursuing 
a centrifugal course, and healing along the inner border while 
it progresses in the line of the external margin. Again, the 
serpiginous ulcer is seen with an evident tendency to penetrate 
into the substance of the skin, and to exhibit sharp, well-defined, 
hardened edges. It is often developed upon the integument of 
the larger articulations, as about the knee and elbow ; and when 
it heals, it leaves a dark-red, ridgy cicatrix, as if the skin had 
recovered from the burn of a hot iron. In some instances, this 
variety of serpiginous ulcer undermines the cutaneous integu- 
ment here and there, without actually destroying it to the full 
extent of its course ; and the overhanging skin conceals a portion 
of the ulcerated surface. 

When tubercles are situated on the face, the copper color is 
generally sufficiently distinct to mark the disease as the off- 
spring of the venereal poison. It has already been observed 
that, in some specimens, it is not a little difficult to distinguish 
syphilitic tubercles, when situated upon the face, from the erup- 
tion of acne indurata ; especially is the difficulty increased in 
persons of a sallow or brunette complexion. The most skilful 
eye will be at a loss to decide. Indeed, it would be unjust as 
well as unscientific to form a diagnosis from visual evidence 
alone. 

There is another variety of tubercles, which, fortunately, is 
very rare. It comes on the forehead, alse nasi, near the angle 
of the mouth, on the tongue, and sometimes at the aural pa- 
vilion. These tubercles always ulcerate ; but the discharge is 
scanty and of viscid consistence. They are sometimes described 
under the name of perforating syphilitic tubercles. They are 
likewise known by the title of syphilitic lupus. They occasion- 
ally unite into one common mass, and cause considerable tume- 
faction. The disease commences like a reddish nodule, without 



TUBERCULAR SYPHILITIC ERUPTIONS. 345 

well-defined limits. It soon increases in activity ; and on 
account of the peculiar diffused redness of the surface, which 
for a time is a prominent feature in the case, it has been desig- 
nated the lupous efflorescence. Sometimes the tubercles will 
disappear for a while, but they usually return and perform a 
horrible work of destruction. Softening and ulceration proceed 
from their apices, and penetrate slowly until the parts are com- 
pletely demolished. At first a small, deep, perpendicular sore 
is formed. It yields a very little exudation of semi-purulent 
matter. A thick crust is produced, beneath which the ulcer- 
ative process invades the adjacent soft tissues, which in turn 
give way ; and if the disease be located on the nasal organ 
the most revolting mutilation is sure to take place. This kind 
of tubercular syphilide bears a close affinity to lupus both in its 
general features and in the chronic course which it pursues. 
It often exists in association with a carious condition of the 
vomer or other nasal bones. Such cases generally terminate in 
nearly a total destruction of the nose, in spite of all treatment. 
The malady has been confounded with cancer. Although its 
local ravages may equal those of the most malignant variety of 
the latter, they are attended with much less pain, and give rise 
to much less constitutional disturbance, than usually accompany 
cancerous affections. 

Treatment of Tubercular Eruptions. — In whatever man- 
ner tubercles may be developed, whether in the aggregated 
form, or whether they are sparsely disseminated upon the face, 
trunk, and extremities, the treatment which they require is 
substantially the same. 

The first point to be definitely settled is, as in all constitu- 
tional symptoms, to adjust a suitable hygienic course, which the 
patient should feel bound strictly to pursue. It is but too often 
that we have occasion to break in upon divers irregularities and 
improprieties of habit in which the victim of syphilis indulges,. 
and which, if not abandoned^ will tend directly to oppose and 
render abortive the best remedial measures which the physician 
can employ ; nay, more, such excesses will give strength to the 
syphilitic virus, while at the same time they enfeeble the organi- 
zation which it pervades. 

A good, nourishing diet should be allowed, and spirituous 



346 GONORRHOEA AND SYPHILIS. 

and fermented liquors be prohibited. If their abandonment be 
a privation, the more urgent the reason for this prohibition. 
Both parties should understand, if they do not already know, 
that a due regard to the general health is a matter of impor- 
tance no less than the skilful use of medicines. The patient, if 
he be so disposed, can do a vast deal towards the subjugation of 
his intractable disorder. The physician can boast of no specifics. 
He can exert his talents in the application of various substances 
in the materia medica, with a view to extinguish the morbid 
phenomena as they arise from time to time in long succession ; 
and he may, ordinarily, feel justified in encouraging the poor 
sufferer that he will finally recover a fair amount of health. 
There are many syphilitic individuals who, to all appearance, 
wholly regain their original vigor of body and mind. Others 
there are, and the number is not small, who never enjoy this 
boon. 

What has already been offered, respecting the constitutional 
management of syphilis in its earlier stages, leaves but little 
room for any additional suggestions in this place. Whether the 
tubercles are all in a state of induration, or whether a portion 
of them have passed into a state of softening and ulceration, the 
bichloride of mercury may be employed to the amount of one- 
tenth of a grain, morning and evening, provided there is no 
indication to the contrary. If this salt have already been suf- 
ficiently tried without benefit, the iodide of potassium, or some 
other remedy of acknowledged reputation, must be selected. 
The carbonate of ammonia has been known to accomplish a 
speedy cure where mercurial preparations have failed. It may 
be administered in the form of julep, commencing with one 
drachm of the salt in the course of the day, and gradually in- 
creasing the quantity until the patient takes two or three 
drachms in the twenty-four hours. 

I have often made trial of the iodide of iron in the latter 
stages of secondary ulcerations, but have never had the good 
fortune to realize any marked beneficial effect from its ad- 
ministration. I have ordered it in small and in liberal doses, 
with the hope that it might operate as a tonic to the blood, the 
humoral character of which we cannot doubt at this crisis of 
the syphilitic disease, if we ever did before. The ferruginous 
preparation here mentioned has been considered, and even now 



TUBERCULAR SYPHILITIC ERUPTIONS. 347 

is regarded by some practitioners, as a powerful agent when 
prescribed in large quantities, and as particularly adapted to 
cases where a decided syphilitic cachexia exists, or a state of 
anaemia combined with scrofula. This salt is readily decom- 
posed ; and I have always been in doubt whether, even when 
given in the form of syrup, it can be preserved in its normal 
state for any great length of time. At any rate, my want of 
success with it has induced me to relinquish its use, and to em- 
ploy in its stead the potassio-tartrate of iron, or the iodide of 
potassium, together with other tonics, such as nitric acid and 
quinine. I have confidence also in the efficacy of sarsaparilla, - 
given largely for several successive weeks. Warm baths, or, 
what is still better, vapor baths, should likewise be admin- 
istered. They not only purify the surface, but essentially pro- 
mote capillary circulation, and render more active the sebaceous 
and sudoriparous apparatus, and thus greatly aid in eliminating 
\he morbific element from the system. 

The course above suggested will usually accomplish the 
resolution of most, if not all, of the indurated tubercles ; and 
'if any have passed into a suppurative condition or stage of 
ulceration, they will also undergo an amendment from the same 
constitutional measures. Arsenical preparations, the decoction 
of rumex obtusifolius, the decoction of Feltz, the decoction of 
Zittman, directions for which can be found in the books, will all 
be useful, and should be tried in cases that prove particularly 
obstinate. 

Local Treatment. — The nitric oxide of mercury ointment 
will constitute a valuable application to indurated tubercles. 
If they are situated on the face, their speedy removal will afford 
great relief to the feelings of the patient ; and a small quantity 
of the unguent rubbed upon them at night will assist in hasten- 
ing this result. The iodide of sulphur ointment and the citrine 
ointment are likewise very efficient remedies. If the circum- 
stances of the patient will allow of these appliances during the 
day, he will be rid of the morbid growths all the sooner. 

As local applications to ulcerated surfaces, following the 
softening of tubercles, the compound tincture of Benzoin, the 
nitric acid, the aromatic wine with opium, the solution of 
potassio-tartrate of iron of different degrees of strength, the 



348 GONORRHOEA AND SYPHILIS. 

tincture of iodine, a dilute solution of chloride of soda, etc., 
will naturally suggest themselves to the surgeon as important 
auxiliaries to the constitutional treatment. 

If the practitioner be dealing with a serpiginous ulcer, which 
is very apt to eat its way under the skin in a tortuous manner, 
the compound tincture of iodine may be applied directly to the 
ulcerated surface where the matter has burrowed, and it maybe 
allowed to impinge upon the entire walls of the ulcer. A 
drachm or two of the tincture may be used every second day. 
Its employment should be followed immediately by the use of 
warm water, and thus the iodine will be at once diluted and 
washed out. This method of local treatment will frequently 
succeed satisfactorily. The employment of the iodine does not 
give much pain. The morbid secretion from the ulcer is spread 
over its surface as a sort of varnish, and in a good degree pro- 
tects it from any violent or very painful effect. Patients do not 
complain of the severity of the operation. When the ulcer is 
brought into a healthy state, which will be evinced by its 
carneous, granulating aspect, it can generally be kept so by the 
constant use of the weak nitric acid lotion, half a drachm to' 
the pint of water. 

When the process of undermining the skin reaches to any 
great extent, so that local remedies cannot be used and retained 
on lint to advantage, it will be best to slit open the loose integu- 
ment throughout the whole distance with a spear-pointed 
bistoury and thus obtain a better chance for the action of topical 
applications. 

If the ulcers become painful they will require to be dressed 
with a warm solution of the extract of opium several times in 
the day, and at night with an ointment containing prussic 
acid. 

ft. Acidi Hydrocyanici, 5 ss. 

Cerati Siraplicis, . S iss. M. 

Bits of lint, smeared with this cerate, should be placed in 
contact with every accessible portion of the sores. 

If the ulcers remain indolent, the following solution will 
often prove a convenient and useful stimulating dressing, when 
others fail to answer the purpose : — 



TUBERCULAR SYPHILITIC ERUPTIONS. 349 

R. Plumbi Acetatis, 9ss. 

Ammoniae Carbonatis, 5 ss. 

Aquae Fontanae, § viij. M. 

Apply on lint. 

If at any time the ulcers assume an inflammatory aspect, a 
local antiphlogistic treatment will be appropriate. Should a 
sloughing condition take place, the nitric acid undiluted, or the 
compound tincture of Benzoin, will be indicated for topical use. 
The chloride of zinc is a favorite dressing with some surgeons. 
The following is a medium strength : — 

K. Zinci Chloridi, 5j. 

Aquae Fontanae, . . § viij. M. 

Dossils of lint, saturated with this solution, are to be laid 
upon the diseased surface, and renewed thrice daily. 

Bromine. — This is an elementary substance obtained from 
bittern and possessing many analogies to chlorine and iodine. 
It is sparingly soluble in water. As a therapeutic agent it has 
recently acquired a reputation among some of our army sur- 
geons, who have employed it as a caustic in cases of sloughing 
ulcerations and gangrene, instead of nitric acid. But it remains 
to be seen whether its superiority over the acid will be fully demon- 
strated after having been more generally used in surgical practice. 

It is not, however, particularly as a caustic that I propose to 
speak of it, but rather to commend its use in a very diluted 
state as a constant lotion to atonic ulcers and those of a phage- 
denic character requiring a stimulating dressing. The bromide 
of potassium can also be administered internally in cases where 
the iodide of potassium is indicated, but where the patient, from 
peculiar idiosyncrasy, is unable to tolerate it. The bromide, 
however, is quite inferior to the iodide for internal use. It is 
also of less value than the iodide of soda. 

The subjoined formulae for the use of the bromine and the 
bromide of potassium, are the principal ones in vogue : — 

For Internal Use, 

No. 1. R. Potassii Bromidi, 5 ss. 

Glycerinae, § ss. 

Aquae § iiiss. 

M. Ft. mistura. 

Dose. — 5 ij- thrice daily in half a gill of cold water. 
30 



350 GONORRHOEA AND SYPHILIS. 

No. 2. R. Potassii Bromidi, 9j. 

Brominii, gtt. viij. 

Aquae, §iv. 

M. Ft. mistura. 
Dose. — 3 ij- thrice daily in half a gill of cold water. 

For External Use. 

No. 1. R. Brominii, gtt. xvj. 

Aquae, § viij. 

M. Ft. lotio. To be applied with lint as a constant dressing to 
indolent ulcers. 

No. 2. R. Brominii, gtt. x. 

Potassii Bromidi, 9ij. 

Aquae, § viij. 

M. Ft. lotio. In the same cases as the preceding. 

No. 3. R. Brominii, gtt. xx. 

Cerat. Cetacei, § i. 

M. ft. unguent. To be applied to the sores night and morning, 
on lint. 

No. 4. R. Potassii Bromidi, gr. x. 

Brominii, gtt. viij. 

Cerat. Cetacei, § j. 

M. ft. unguent. In the same cases as the last.* 

MUCOUS TUBERCLES. 

Syphilitic patients do not all experience the same constitu- 
tional accidents ; nor do these accidents uniformly exhibit them- 
selves in the same undeviating succession ; neither does it follow, 
as a matter of certainty, that a person who has tertiary syphilis 
must previously have had secondary symptoms. In some rare 
instances the primary disease and the tertiary manifestations 
coexist, although Ricord is entirely absolute that primary, con- 
secutive, secondary, transitionary, and tertiary accidents follow 
each other with the most perfect regularity. This order in the 
series of morbid syphilitic phenomena he believes, from clinical 
observation, to be uniform, unless interfered with by treatment. 

It is sometimes difficult to determine which of the consecu- 
tive constitutional affections should claim attention first ; and 

* Caillault on the skin, p. 287. 



TUBERCULAR SYPHILITIC ERUPTIONS. 351 

again it is not always easy to assign to every morbid develop- 
ment its most appropriate position in the natural history of the 
complaint. Mr. Wilson arranges mucous tubercles in the second 
group or period of syphilodermata, along with the tubercula 
ulcerantia, superficial and deep, lupus ulcerosus and tumores 
gummati ; that is, as belonging to tertiary syphilis. But 
mucous tubercles are frequently evolved in a few weeks after 
the existence of the primary chancrous sore, and are sometimes 
the earliest constitutional developments that appear. I now 
happen to have under my care a young girl of sixteen, who 
contracted a chancre in the month of April. Eight weeks after 
exposure, mucous tubercles in great profusion sprung up around 
the anus, then appeared upon the perinaeum, then upon the 
right labium. Soon afterwards a papular eruption spread itself 
extensively over the trunk and limbs, and at a later period 
secondary lesions showed themselves within the mouth. This 
is far from being a solitary or rare instance of constitutional 
syphilitic phenomena arising in the order above stated. Such 
cases induce me to regard mucous tubercles as belonging to 
secondary syphilis rather than to tertiary. They are designated 
by several correlative terms, or synonyms, as muco-cutaneous 
papules, condylomata, pustule plate, tuber cute muqueux, papules 
muqueuses, etc. They are developed upon the moist surfaces 
of the genital and anal regions, upon the mammas, and in the 
axillae. They are occasionally seen sprouting from the umbili- 
cal depression, within the buccal cavity, within the nostrils, and 
just at the orifice of the external auditory canal. Occasionally 
they are observed at the commissure of the lips, and about the 
roots of the nails. They are found in women much more fre- 
quently than in men. With the former, they mostly infest the 
inner surface of the labia majora. In the latter, they are 
usually seen forming a broad wall around the anus. A specific 
feature in regard to them is that they rarely, if ever, proceed 
to normal ulceration, unless exposed to long-continued irritation. 
They have a smooth' or granular surface, and are of a deep, 
dull red or copper color. Where no .measures have been taken 
to arrest their progress they often spread over large portions of 
integument. A few days since I saw, in consultation, a young 
Englishman, on whom these mucous tubercles had been grow- 
ing unmolested for several months. They occupied the whole 



352 GONORRHCEA AND SYPHILIS. 

perineal region, the scrotum, the root of the penis, the inguinal 
folds, and the upper part of the thighs. Upon the latter and 
upon the scrotum and penis they were mostly isolated, and 
projected very prominently ; on the perinaBum and around the 
verge of the anus they were closely crowded together, and 
presented a dirty grayish coat on the surface, consisting of 
epithelium. They were moist and elastic to the touch, and 
sufficiently disgusting to the olfactories. They had been sub- 
jected to no treatment, not even to that by cold water. At 
times, after much exercise, they occasioned a slight degree of 
pain, but no other inconvenience. The patient had other vene- 
real maladies, derived from a chancre which he caught two 
years previously. 

Mucous tubercles commence by increased vascularity in the 
spot from which they are about to germinate. Sometimes they 
are developed with great rapidity, and are more or less excori- 
ated. When they occur upon the mucous membrane of the 
labia, where they are always subject to gentle pressure, they do 
not ordinarily grow much above the adjacent surface. If they 
are evolved in groups, and become confluent, they may exhibit 
in the aggregate an extensive flat surface, while, if not subjected 
to pressure, the entire warty mass may be elevated two, three or 
four lines above the surrounding integument. When seated 
upon the dartos they are generally solitary, and reach an. 
extraordinary elevation and size, and are often traversed by 
fissures, from which a filthy, serous exudation oozes, charged 
with a most revolting smell. 

Many specimens present in their superficial substance a 
light yellow appearance, which is due to the presence of swollen 
sebaceous follicles. Their soft, pultaceous consistence is caused 
by an infiltration of serous fluid into the minute connective 
tissue cells which abound in the morbid growth. The condylo- 
mata are constituted of enlarged papillae, and have their origin 
in the corium. The accessory organs of the skin also become 
involved. The sebaceous glands and follicles increase in size, 
and subsequently a formation takes place of the epidermic-like 
cells ; a process which does not occur in the normal condition of 
the sebaceous apparatus. 

In some cases the morbid growths in question will remain 
upon the parts for a long period without annoyance to the indi-. 



TUBERCULAR SYPHILITIC ERUPTIONS. 353 

vidual ; in others, if neglected, they occasionally give rise to 
superficial ulcerations, and harass the patient not a little. 
When they infest the anal region they occasionally give rise to 
fistulous sores ; and inflammation and stricture of the rectum 
have been known to occur in consequence of them. The 
stricture is usually situated about two inches from the verge of 
the anus ; its form is that of a double funnel, and it gives rise 
to a sero-purulent discharge occasioned by ulcerations of the 
mucous membrane ; the fasces are liquid, and are expelled 
without much difficulty. 

In a case which I recently saw, at one of our public institutions, 
the tubercles covered the clitoris and the entire mucous surface 
of the labia. In some places they had the cauliflower or rasp- 
berry appearance. There was engorgement of the mucous sur- 
face as far as the examination could extend without the use of 
the speculum. The epithelium of the labia was disorganized 
and at several points detached, thus showing excoriations, from 
which a trivial discharge was constantly oozing. This, added to 
the natural exhalation from the parts, produced a nauseous 
effluvium, which it is unnecessary to describe particularly. The 
mouth and throat likewise exhibited consecutive lesions. The 
woman had been married about eight months, and dated her 
sickness from that event. For several weeks she suffered con- 
siderably from constitutional disturbance arising from her vene- 
real symptoms. She was pregnant. 

These mucous tubercles or patches may appear upon any part 
of the body of an infant ; whilst, on the contrary, in the adult, 
they are confined to the mucous tissues and to those portions of 
skin that are peculiarly delicate and exposed to friction. It is 
important that they should not be confounded with other tuber- 
cular syphilides, which are non-contagious, whereas the mucous 
tubercle or broad condyloma takes the first rank among the 
secondary or constitutional symptoms of syphilis, which are com- 
municable by contagion. 

The mucous tubercle usually appears at an earlier period than 
the other variety, and is strictly a secondary lesion. In some 
instances, however, the mucous patches are developed upon the 
tongue or other parts within the mouth and elsewhere, while the 
ordinary syphilitic tubercular eruption is disseminated upon the 
face, trunk and limbs. 
30* 



354 GONORRHCEA AND SYPHILIS. 

It is sometimes no easy matter to make out the differential 
diagnosis of these mucous tubercles, and they afford a good 
theme for clinical study. 

Treatment of Mucous Tubercles. — The tincture of the 
muriate of iron, touched upon the morbid growths morning 
and evening by means of a bit of soft sponge, will frequently 
cause their immediate disappearance. A solution of the nitrate 
of silver applied daily in the proportion of one drachm to the 
ounce of rose-water, will also act with great rapidity and efficacy 
in causing them to wither away in a short time. If the tuber- 
cles have become greatly hypertrophied and present an exten- 
sive vegetating surface, the concentrated nitric acid, or the acid 
nitrate of mercury, will be found more beneficial and appropriate 
than any other topical remedy. Either of the two fluids last 
mentioned may be applied about every four days, until the con- 
dylomata are nearly annihilated, after which the solution of 
silver should be substituted to finish what remains to be done 
locally to these excrescences. When they are situated on the 
labia, or around the anal aperture, a piece of lint, moistened 
with a weak solution of chloride of soda and placed between 
the opposing surfaces, will contribute to the comfort of the 
patient. As a daily dressing the black wash sometimes proves 
efficacious. The submuriate of mercury, sprinkled upon these 
abnormal appendages once in the twenty-four hours, will accom- 
plish their destruction in a satisfactory manner ; and where the 
disease exists in young children, and where the application can 
be made without inconvenience, it is to be preferred to all other 
local means. Before employing it, the tubercles should be 
thoroughly cleansed with chlorinated water, and wiped dry. 

Constitutional Treatment. — The bichloride of mercury, 
to the amount of one-eighth or one-tenth of a grain, twice a 
day, may be prescribed for an adult affected with this variety 
of tubercles. 

The salt should be continued until its specific effects begin 
to display themselves ; after which it will be advisable to substi- 
tute the iodide of potassium. In conjunction with the mercu- 
rial treatment, a tonic course will, in most cases, -be requisite. 
The tincture of the muriate of iron, or the potassio-tartrate of 
iron, and a generous diet, will be appropriate. 



pl^t. 




Pustular Syphilis 



CHAPTER XXXI. 

SYPHILITIC PUSTULES. 

The pustulae may be considered as forming the third link in 
the metamorphic development of the syphilides. The papule 
is usually but the prelude of the tubercle. The pustule is 
engrafted upon the tubercle, and the ulcer appears next after 
the pustule. Such is the order of succession in most cases, but 
not in all. The normal series may be broken by the course of 
treatment, and by other intercurrent circumstances ; so that we 
are unable to say whether the vis medicatrix natures would pur- 
sue, in all cases, an undeviating method in this strange work of 
development, which is neither more nor less than the result of 
the various surgical experiments which nature institutes in her 
own self-defence. 

The syphilitic pustule is formed upon the summit of the 
tubercle, which softens at this point, while the part that reposes 
upon or within the derma may remain unchanged. Thus the 
pustule will sometimes linger upon an indurated base for many 
weeks, and will yield but a small quantity of fluid, and this 
will be very different in composition from that of ordinary 
impetigo, the pustules of which are always of a decidedly 
inflammatory character, and always furnish laudable pus ; but 
it is seldom that true, yellow pus is elaborated from syphilitic 
pustules, although some of them belong to the impetiginous 
form of eruption. (Plate VI.) 

These pustules are extremely sluggish in their formation, 
and after occupying the derma for several weeks, or even 
months, will heal ; and thus, to one not familiar with their 
behavior, they give promise of future good to the patient ; but 
anon, a new crop springs up on some distant portion of the 
integument, which shows that the disease is still persistent in 
the economy. Sometimes the pustules degenerate into con- 

(355) 



356 GONORRHOEA AND SYPHILIS. 

secutive ulcerations of greater or less depth, and secreting a 
foul, heterogeneous mixture of blood and serum, with perhaps 
the addition of a small quantity of pus globules, they refuse to 
improve under the most judicious management. They have 
been divided by Willan into two groups. First, those that 
acquire a large size, are seated on an inflamed and indurated 
base, terminate in a dense, brown scab, like the pustules of 
ecthyma, variola, and vaccinia, and are called phlyzacious pus- 
tules. The second variety is known among dermatologists as 
psydracious pustules. They are small, scattered, or in clus- 
ters, and terminate in crusts of various irregular forms, as the 
pustules of impetigo, acne, and sycosis. Alibert gives to them 
all the title of crustaceous pustular sypMllde. The foregoing 
distinctions, although they may be clear and important to the 
fastidious mind of the professed dermatologist, are, after all, a 
matter of secondary consideration ; for the pustules require no 
special difference either in constitutional or local remedial meas- 
ures. The eruptions are expressive of great debility and 
exhaustion of the system, which has now maintained a cease- 
less warfare for a long period against its relentless foe. 

The phlyzacious pustules that arise from the syphilitic poison, 
and bear a general resemblance to ecthyma, are among the 
most remarkable and important we meet with. They are larger 
than those arising from the apices of tubercles. They are not 
numerous at any one time. They appear in successive crops, 
but at distant intervals. They are disseminated over various 
parts of the body and limbs, and also upon the face. They 
have a broad, ulcerated base, are flattened, and frequently show 
a central depression like that of small-pox when on the decline. 
The epidermis is pushed forward by the presence of a dark, 
thick, viscid, sanguinolent secretion, and the pustule and scab 
are encircled by a purplish-red, not copper-colored, ring of 
subacute inflammation. If the disease be not arrested at an 
early period, ulceration of a superficial kind takes place be- 
neath the scab, which is constantly pushed forward by new 
accumulations of ichorous, semi-purulent matter ; and this, in 
turn, hardens into an incrustation. The cuticle becomes de- 
tached around the border of this incrustation, which expands 
by increments of concentric zones, until the thin, brown, 
pointed, elevated, and rough crust of rupia prominens is pro- 



SYPHILITIC PUSTULES. 357 

duced. When this curious hollow cone is complete, the origi- 
nal stratum which formed its base becomes its apex ; and of all 
the morphological transformations that occur in the history of 
syphilitic pathology, none present more hideous or extraordi- 
nary features than the physiognomy of rupia prominens. 
Judging from outward appearances alone, it would be im- 
possible to trace any affinity or relationship between this mal- 
ady and its progenitor, the insignificant, harmless-looking pim- 
ple, the size of a pin's head, peering out from the integument 
of the penis in the form of chancre. Individuals who are the 
subjects of this devastating form of syphilitic affection, are 
often reduced to the lowest degree of prostration. Life, indeed, 
may be spared, — it usually is, — and, after years of suffering, 
debility, and self-loathing, the unfortunate victim may grad- 
ually emerge from his deplorable condition, and regain, in part, 
his original health. In a majority of cases, however, it is only 
in part, and he is under the imperious necessity of watching 
and guarding at all times, and with unremitting solicitude, the 
shattered remains of what, perhaps, was once a splendid and 
vigorous frame. 

Professor Wilson, in the last edition of his work on diseases 
of the skin, takes occasion to modify the views he formerly 
expressed in regard to pustular eruptions developed under the 
influence of the venereal poison. For instance, he no longer 
considers it correct to speak of impetigo syphilitica, this pus- 
tular condition being nothing more than a syphilitic lichen 
passing into a state of ulceration. 

With the exception of rupia, it is probable that the different 
kinds of syphilitic pustules are in fact but a secondary stage of 
lichen or tubercle. A careful observation of the origin of the 
pustules, I think, will sustain this view, and we need have no 
difficulty or hesitation in adopting Wilson's theory, which is 
that the only eruption coming strictly under the denomination 
of pustular syphilis is rupia, an affection depending especially 
on a pyogenic condition of the constitution. But it would be a 
digression from the design of this work to proceed more at 
length into discussion here, with a view to settle any unimpor- 
tant differences which the pustular as well as other syphiloder- 
mata present at different epochs of their history. 

Wherever the pustules are situated, they are very apt to 



358 GONORRHOEA AND SYPHILIS. 

terminate in small superficial ulcers. These latter do not, as 
a general thing, show a disposition to extend either in depth 
or otherwise, but usually heal without difficulty ; and herein 
they differ essentially from the deep and destructive ulcers that 
originate from the subcutaneous tubercula gummata, and which 
belong to the tertiary group of symptoms, and require a con- 
stitutional and local management different from that which is 
applicable to the secondary ulcers. 

Rupia makes its first appearance in purulent bullae, which are 
always isolated. The eruption is more frequently developed 
on the lower extremities than elsewhere. No portion of integ- 
ument, however, is exempt from its invasion. There are two 
perfectly distinct varieties of the complaint, according to the 
thickness and form of the crust, which is evolved by the gradual 
concretion and drying up of the fluid contents of the bullae, so 
that we have rupia simplex, and rupia prominens. The disease 
is extremely chronic and slow in its progress, and is one of the 
most loathsome affections that come upon the human skin. It 
indicates the very lowest degree of impoverishment of the 
system, and is sometimes accompanied by purpura upon the 
extremities, and by serous effusion into the several cavities 
of the body. I have at the present time a young married 
man under my care for this pustular syphilitic malady. His 
condition is shattered through the joint influence of intem- 
perance, syphilis, and quack medicines. Six weeks ago, nu- 
merous dots and small patches of purpura appeared suddenly, 
first about the ankles, and shortly afterwards over nearly the 
whole extent of the legs and thighs. I have seen one other 
instance of purpura coexisting with rupia. In both persons 
the former disappeared in about three weeks. Rupia often 
shows itself in its various stages at the same time, thus giv- 
ing to the patient a most extraordinary appearance. In some 
spots small, livid pimples will be seen ; in others those of a 
larger growth, and filled with sanguineo-purulent fluid ; others, 
still farther advanced, will be surmounted by thin, yellowish- 
brown scabs. In some individuals the incrustations present a 
greenish appearance, and look like vegetable fungi sprouting 
up from the integument. They acquire different degrees of 
altitude and circumference. In shape and general aspect these 



SYPHILITIC PUSTULES. 359 

crusts are somewhat irregular ; hence the epithets " limpet- 
shell," and " oyster-shell," to which they have been compared. 

Case. — Mrs. B., aged thirty-six years, residing in a neighbor- 
ing city. Four years previous to my seeing her she received 
the venereal poison from her husband one week before his 
death, which took place suddenly from an injury. The woman 
had never been under the care of any regular practitioner ex- 
cept at odd intervals. The tampering of quacks constituted 
the principal medical attentions she had received, and the dis- 
ease may be said to have pursued very much its own course. 
It was in the month of July that I saw the patient for the first 
time. I found her sitting in a chair. She had been confined 
to her room for about six months, was able to sit up in bed or 
in her chair nearly all day, and could walk across the room. 
She was emaciated and anaemic, and as filthy as she was thin. 
The catamenial function had been suspended for ten months. 
The face was covered with some eighteen or twenty rupial 
crusts, from the fourth to the half of an inch in diameter, and 
in length some of them had grown to nearly an inch. They 
were distributed nearly symmetrically on parts corresponding 
with each other, not only on the face but elsewhere. Upon 
the back of the hands, and upon the dorsal surface of the 
thumbs and fingers, especially on the integument covering the 
joints, they were particularly numerous. On the upper por- 
tion of the back, the scapulas, about the shoulder-joints, along 
each clavicle and arm, they had also formed in great numbers, 
and had, in some instances, reached the size of an inch in diam- 
eter and as much in length. On the thighs and legs they were 
likewise thickly developed. About the knee-joints they had 
acquired the greatest dimensions. A few had a circumference 
equal to a half dollar. Numerous cicatrices were seen where 
former rupial sores had healed, and several ulcerated patches 
existed from which the crusts had fallen off. These atonic 
ulcers were all superficial. The woman had no relish for food : 
the bowels were costive, the tongue slightly coated, and having 
upon its edges the impressions of the teeth very deep ; the 
pulse was quick and feeble. [Vide Frontispiece, Plate I.] 

Quinine, chalybeates, the iodide of potassium, cleanliness, 
and a generous diet were prescribed. In four months the 



360 GONORRHOEA AND SYPHILIS. 

patient recovered health and strength sufficient to take short 
rides in the cars, and to visit friends in her immediate neigh- 
borhood. I saw her but a few times, and was unable to keep 
an unbroken thread of her history, as she had no permanent 
abiding-place ; and whether a perfect cure took place is more 
than I know, although I do know that the rupia did entirely 
disappear. 

Both forms of the eruption now in review are occasionally 
seen on the same individual, as once happened to be the fact 
with a female patient of mine, whose case I will here briefly 
submit. 

In October, 1855, I was requested to visit a woman who had 
been married seven years, was the mother of two healthy 
children, one five, the other three years old. She was very 
tall, slender, and thin in flesh. She reported that for eighteen 
months different portions of her skin had been the seat of 
numerous ulcerations. At the time of my visit the principal 
ulcerated patch occupied the right elbow-joint, and a large 
portion of integument covering the inferior extremity of the 
humerus to the distance of three or four inches. The ulcer 
was superficial and irregular in outline — serpiginous. Some 
twelve or fifteen small sores were scattered elsewhere over 
the extremities, and the cicatrices of former ulcers were suf- 
ficiently abundant. The syphilitic character of all these ex- 
ternal manifestations was well marked. During a period of 
eight months before I saw the patient she had lupus exedens, 
or, in other words, syphilitic ulceration of the soft part of the 
nose. The alae and cartilaginous septum were destroyed, and 
the disease was still active ; in fact, it ceased its .ravages only 
with the loss of the entire organ. In April, 1856, three or 
four bullae made their appearance upon the dorsal aspect of 
the left fore-arm. Soon after this one bulla was developed 
just above the superciliary prominence, near its commence- 
ment at the root of the nose, and another came upon- the in- 
tegument of the left side of the lower jaw, one inch from the 
symphysis. The latter specimen became an object of special 
interest, as it was the only one that furnished the crust of 
rupia prominens. Several weeks were consumed in the de- 
velopment and decline of this rupial sore. The woman, ac- 



SYPHILITIC PUSTULES. 361 

cording to request, was careful not to disturb it by picking 
or rubbing. The crust was produced very gradually, each 
layer being preceded by an erythematous band, which widened 
from time to time ; the cuticle subsequently became distended 
with a thick opaline, semi-purulent fluid. In six weeks the 
crust completed its growth. It had a slight downward curve 
near its apex, projected about an inch from the jaw, and was 
an inch in diameter at its base, which was in form a com- 
pressed circle. None of the other crusts assumed this pecu- 
liar prominent aspect. They became considerably thicker in 
the central portion than at the circumference, presented a 
large circular base, were for a long time very adherent, and 
on being cast off spontaneously, an ill-looking ulcer, having 
no disposition or power to furnish healthy pus or granulations, 
was brought into view. 

One or two points hi connection with the foregoing narra- 
tive I must presume to submit to the reader for consideration. 
The most careful inquiries failed to bring out the whole truth 
touching the history of this case. The husband denied all ex- 
perimental knowledge of syphilis in his own person ; and I 
believed him. The woman ignored all primary symptoms, as 
developed in the usual localities or any other place ; and I did 
not believe her. I was confident that she was the transgressor. 
The parties were in health at the time of marriage. Now the 
query is, when did the woman contract the disease, before 
marriage, or after the birth of the second child ? She never 
suffered abortion, and both children were healthy. The husband 
believed the infection took place anterior to matrimony. 

Treatment of Pustular Syphilis. — For this I must refer, 
to a considerable extent, to the principles already adduced. 
If I were to offer any further considerations or suggestions, 
they would be in reference to the importance of attending 
now, more than ever, if possible, to the employment of all the 
hygienic, means that can be summoned, with a view to rescue 
the patient from impending danger ; for he is often so. sadly 
reduced that medicines seem to be nearly inert, or perhaps ab- 
solutely injurious. When such a case occurs we may inter- 
pret the failure of the system to respond in the usual manner 
31 



362 GONORRHOEA AND SYPHILIS. 

to the action of remedies, to a loss of tone, which nothing can 
restore but a judicious plan of diet, regimen, etc. 

If the individual lias been accustomed to the habitual use of 
wine, or to other alcoholic stimulation, his nervous organization 
may not quietly bear their entire prohibition, unless a substitute 
be provided. The carbonate of ammonia julep, to the amount 
of §iv. during the day, will appease the cravings of this appe- 
tite more satisfactorily to the patient than any thing else which 
it would be expedient to give. The julep may be administered 
in a weak infusion of hops. It will not be advisable to inter- 
rupt the previous habits of the man in the particular here 
alluded to, and leave him nothing to fall back upon. 

In pustular syphilis the practitioner meets with so many 
degrees of severity in the symptoms, with so many complica- 
tions, with such a diversity of constitutions, and other circum- 
stances appertaining to the general health, that he cannot 
follow any absolute rules of practice that shall be applicable to 
all persons. 

Although some authorities tell us of lentigo, of miliary pus- 
tules, of impetiginous pustules, of two forms of ecthymatous 
pustules, etc., it seems hardly worth while to stray away into 
a wilderness of words, and confuse the mind by descanting upon 
the existence and treatment of these fancied varieties of syph- 
ilitic pustules. I have already signified my disposition to adopt, 
with slight variation, the views and the nomenclature of Pro- 
fessor Wilson ; that is, to consider these pustules as only a 
secondary stage of the papular or tubercular affection. The 
only exception that need be allowed is in reference to ecthyma. 
It would be difficult to point out any very characteristic fea- 
tures by which to distinguish many specimens of this eruption 
from rupia. In external characters the two are sometimes 
closely allied, and are developed under similar conditions of the 
economy. They are often met with, side by side, in .the same 
individual, and appear to be only different degrees of the same 
inflammatory process ; and no variation whatever is required in 
our efforts to cure them. 

As the practical surgeon, who is qualified to take charge of 
patients requiring the operation of lithotomy, is usually com- 
petent for any emergency that may demand his professional 
skill, so, it may be presumed, the medical practitioner, who can 



SYPHILITIC PUSTULES. 36S 

conduct cases of rupia to a successful termination, may regard 
himself as able to manage the lesser pustular forms that arise 
in syphilitic patients. 

The iodide of potassium often exerts a salutary action over 
the class of accidents now before us, and, in a majority of in- 
stances, no one remedy is more influential in promoting recov- 
ery. The rupial affection quickly gives evidence of amend- 
ment, and the general condition of the patient improves very 
rapidly. The salt just named may be advantageously employed 
conjointly with the compound decoction of sarsaparilla, and 
can be administered for several successive weeks or months, if 
need be. In lichenoid and tubercular eruptions, which are 
purely secondary manifestations, the iodide fails to be useful ; 
but when these have become pustular, and have reached that 
transition state which, so to speak, is midway between secondary 
and tertiary syphilis, or when tertiary accidents have actually 
occurred, then it is that it displays its sanative powers to the 
best advantage. But notwithstanding the symptoms yield so 
readily to its influence, and the patient continues to improve, 
and even, perhaps, may remain to all appearances cured for a 
while, the disease is liable to return. The same remedy can 
again be employed as one of the elements in the treatment ; but 
it will not be advisable to rely upon it as during its previous 
exhibition. The venereal poison still reigns in the system ; and, 
whatever theoretical views we entertain of the action of the 
potassium, we have the clinical fact now before us that it will 
not, alone, eradicate the virus. Where small doses fail, some 
surgeons advise a great increase in the quantity, even to the 
amount of two or three drachms per diem. I have seen this 
experiment work advantageously ; and, on the contrary, I have 
known large doses to be used in rupial pustules and ulcerations 
without producing the desired improvement. Failing of suc- 
cess by such a procedure, I have sometimes witnessed the best 
effects where the tartrate of iron and potash has constituted a 
supplementary article to other remedies. If the patient has 
been subjected to somewhat heroic experiments for a long time, 
with no special benefit to his malady, his system is very liable 
to become irritable and greatly debilitated ; and he seems sud- 
denly to lose all power to tolerate medicines of any description. 
The iodic, or what is still worse, perhaps, the mercurial intoxi- 



364 / GONORRHCEA AND SYPHILIS. 

cation, may be upon him. In such circumstances favorable 
results will probably be realized by allowing him to rest for a 
short period from the use of all potent remedies. Let him 
drink Congress Spring water, let him have a liberal dietetic 
range, let him seek the salubrious country air, if possible, and 
afterwards medical treatment may be resumed with better 
success. 

Mr. Wilson relates an extraordinary instance of rupia exist- 
ing in connection with primary disease. The treatment, in 
this case, consisted in blue pill and opium internally, and black 
wash locally, for the primary symptoms. For the secondary 
symptoms the patient had sarsaparilla and nitric acid at first, 
and opium to relieve nocturnal pains. Afterwards he took 
the iodide of potassium with sarsaparilla. His regimen con- 
sisted of eggs and wine ; then a mutton-chop, with four glasses 
of port wine ; and, as he grew stronger, a pint of stout, with 
two glasses of port wine daily. If numerous ulcerations exist 
in connection with a copious pustular eruption, the patient 
generally suffers extremely, especially during the night, and 
he will require the tranquillizing influence of large doses of 
opium. It is highly important for him to get his accustomed 
sleep. For this purpose, half a grain of sulphate of morphia 
in a drachm of camphor-mixture should be administered at 
bedtime, and, if necessary, let the dose be repeated in two or 
three hours. 

In pustular syphilitic affections the use of mercury is to 
most patients decidedly prejudicial. It is liable to cause 
sloughing and phagedenic ulceration of the skin, and thus 
impose upon the individual great additional misery. 

The rupial crusts may be removed to advantage, provided 
this can be done without employing much force ; but if they 
are quite adherent, they should not be disturbed. Alkaline 
baths and sometimes warm poultices will promote their de- 
tachment ; and the indolent ulcers thus brought to view should 
be touched with the nitrate of silver, or some other less stimu- 
lating substance. Dossils of lint, soaked in a weak solution of 
nitric acid, or in the potassio-tartrate of iron solution, consti- 
tute an appropriate dressing to the sores during the day ; and 
for the night they will need the protection of some mild, gently 
stimulating ointment, as that of the nitric oxide of mercury 
very much diluted. 



SYPHILITIC PUSTULES. 365 

The small pustular and ulcerative affections that appear 
between the toes and at the roots of the nails do well when 
dressed with aromatic wine and opium, balsam of Peru, com- 
pound tincture of Benzoin, or the weak nitric acid lotion. A 
solution of the aqueous extract of opium, with the addition of 
a small quantity of the solution of chloride of soda, makes an 
excellent anodyne and stimulating application : — 

R. Extracti Opii Aquosi, gr. xxv. 

Aqua? Ferventis, § viij. 

Cola, et adde, 

Solutionis Sodge Chloridi, 5vj. M. 

Let the above solution be frequently applied to the sores by 
means of pledgets of lint. 

The position of the foot, while these ulcers are upon it, is a 
matter of no small importance. It should rest upon a cushion 
in a chair or on a sofa. 
31* 



CHAPTER XXXII. 

ALOPECIA. — BALDNESS. 

The principal changes produced in the hair, in consequence 
of the syphilitic diathesis, consist in alteration of its color, 
glossiness, elasticity, and partial or total alopecia. 

The affection last named is not a very frequent accompani- 
ment of constitutional syphilis, although it is sometimes the 
only evident symptom of the presence of the venereal poison 
in the system. Thinning of the hair, however, when it does 
occur in syphilitic patients, is always a source of anxiety and 
mortification ; and, unless the surgeon prescribe for it, the indi- 
vidual will go to some one who will. The affection is not always 
confined to the scalp. It sometimes attacks the eyebrows, the 
eyelashes, the beard and the pubes ; and in rare instances, where 
the syphilitic malady has existed for a long period, the alopecia 
becomes complete over every part of the body and limbs. In 
some cases the falling out of the hair from the scalp is accom- 
panied by a light furfuraceous desquamation of the epidermis. 
The accident has been attributed to the peculiar effect of mer- 
cury on the matrix that supplies the hair. The charge is doubt- 
less unjust. 

The process of decadence can usually be arrested if suitable 
measures are adopted early. The long-continued use of the 
iodide of potassium will frequently accomplish the desired 
object. It should be taken to the amount of five or six grains 
three times a day. The internal administration of mercurial 
agents will not be called for. There are several local applica- 
tions that have proved serviceable. The following lotion is 
worthy of trial : — 

Pfc. Tincturae Cantharidis, 5 i\j- 

Olei Amygdalae Dulcis, 

Liquoris Ammonia?, aa, § j. 

Aquae Mellis, S ij. 

Spiritus Rosmarini, § iv. 

M. Lotion. 



ALOPECIA. — BALDNESS. 367 

Two or three drachms are to be rubbed upon the scalp at 
night. This lotion bears the reputation of bringing out a new 
crop of hair, unless the hair follicles, with their productive 
base or matrix, are destroyed, which is not often the case with 
young syphilitic subjects, although it is the fact in senile 
baldness. 

The following lotion is an agreeable, and oftentimes an effica- 
cious remedy : — 

R. Aquae Colognse, . . . . , 

Spiritus Rectificati, aa, 5j. 

Tincturae Cantharidis, 3 iij» 

Aquae Fontanae, ............ § viij. M. 

A drachm or two may be rubbed into the scalp morning and night. 

Another topical remedy may be prepared according to the 
annexed formula : — 

R. Olei Lavandulae, gtt. xv. 

Essentiae Jasmini, 3 j. 

Tincturae Cantharidis, 3 ij. 

Unguenti Rosarum, |j. M. 

A small quantity of this ointment is to be rubbed into the scalp with brisk 
friction. 

The use of an ointment containing creosote has occasionally 
been followed by a reproduction of the hair : — 

R. Creosoti, gtt. x. 

Olci Limonis, " iv. 

Unguenti Rosarum, § j. M. 

The whole scalp should be thoroughly cleansed, night and 
morning, with the best White Windsor Soap and warm water, 
and afterwards a small quantity of the ointment must be rubbed 
into the bald patches with the finger. Meantime the iodide of 
potassium is to be administered internally. 

The iodide of mercury will sometimes arrest the thinning of 
the hair when occasioned by syphilitic causes, and the subjoined 
preparation can be prescribed : — 

R» Pulveris Camphorae, . 

Hydrargyri Proto-Iodidi, aa, 9s8. 

Unguenti Rosarum, 5 j. M. 



368 GONORRH(EA AND SYPHILIS. 

A small quantity of this is to be thoroughly rubbed into the 
hair at night. It is quite stimulating to the integument ; and 
after a few applications, perhaps every other night will be as 
often as the patient can bear it comfortably. 

The following is a particular favorite with some of the French 
surgeons. It goes by the name of Dupuytren's pomade, 
although it is by no means certain that the preparation can 
rightly claim such paternity : — 

R. Olei Caryophylli, 

" Canellse, aa, gtt. xvj. 

Plumbi Acetatis 7 3 ij« 

Balsami Peruviani, 3 ij- 

Spiritus Bectificati, . % j. 

Medullas Ossium Bovis, § viij. M. 

Another : — 

R. Unguenti Hydrargyri Nitratis, 3 ij. 

Olei Olivse, Sj. M 

The last prescription will often do the patient essential service 
in obstinate cases of alopecia. If the scalp has been the seat of 
syphilitic lepra, or of any tubercular or pustular affection, leav- 
ing a scaly condition of the integument, this compound may bo 
usefully employed. I have also frequently ordered it with satis- 
factory results in cases of non-specific alopecia, accompanied 
with a slight pityriasis. I know of no better topical remedy, 
whatever may have been the original cause of the complaint. 
It may be perfumed with a few drops of bergamot or lavender 
if the patient choose. The hair should be thoroughly brushed 
before using it. 

The hair must be kept very short either with the scissors or 
the razor. The latter should be used every ten or fifteen days 
unless the scalp be too tender to endure the shaving process. 
If the baldness be of very long standing, and occupy extensive 
portions of the skin, and if the latter present a polished, ebur- 
nated appearance, it will be exceedingly difficult to relieve the 
deformity. In some instances it is associated with other con- 
stitutional manifestations, such as pains in the bones, superfi- 
cial ulcerations, or syphilitic lepra, fissures about the angles 



ALOPECIA. — BALDNESS. 369 

of the mouth, partial loss of the nails (syphilitic ungual alo- 
pecia), or inflammation and hypertrophy of the mucous lining 
of the mouth and throat. In all such cases, while any of the 
above named topical remedies are applied to the calvaria, the 
general treatment indicated by these concomitant symptoms 
should be employed 



CHAPTER XXXIIL 
ULCERS ON THE TONGUE. 

Among the most frequent situations for the appearance of 
secondary symptoms are the parts within the mouth. The 
lips, more especially at the angles of the oral aperture, are 
often excoriated, or are the seat of ulcers ; the tongue is 
affected more or less with excoriations, with fissures, with 
ulceration, and induration of its substance ; the gums, the 
uvula, the tonsils, the soft and hard palate, and the posterior 
walls of the pharynx, are all liable to suffer from the violent 
local action of the syphilitic poison. The vascularity of the 
mucous membrane within the buccal cavity, and its intimate 
sympathetic and anatomical relations with the external integu- 
ment, seem to predispose it to participate in many of the forms 
of disease that are developed upon the latter tissue. This 
tendency is not manifest in the syphilodermata alone ; it is 
seen in scarlatina, in measles, in severe eczematous inflamma- 
tion, etc. 

The fauces are generally inflamed, or even ulcerated, at an 
early period in the train of secondary venereal phenomena that 
are manifested upon the mucous membrane. 

In certain patients of a scrofulous diathesis, and of frail con- 
stitution, or who have been scantily supplied with food, or have 
lived on that of an inferior quality for a long period, and thus 
have induced an impoverished state of the blood, we occasion- 
ally meet with eruptions and ulcers so nearly resembling those 
resulting from the venereal virus that we can hardly say 
wherein the difference consists ; and yet nothing can be more 
unfortunate for the physician in private practice than to com- 
mit a mistake in this matter ; for he may thus charge the pa- 
tient with crime he never committed, and, by this false accusa- 
tion, provoke a displeasure which may never have an end. 
Sailors who make long voyages, and who are reduced to short 

(370) 



ULCERS ON THE TONGUE. 371 

rations, and those, perhaps, consisting of poor articles of diet, 
are subject, from these causes, to eruptions and ulcers on the 
skin, and to corresponding appearances on the mucous lining of 
the mouth, which closely resemble secondary symptoms. In 
examining seamen at the Marine Hospital, in Chelsea, I have 
occasionally met with such anomalous cases ; and the question 
has often presented itself, whether an eruption or ulcer upon 
any part of the skin or of the mucous surface can be pro- 
nounced, per se, to be syphilitic, unless accompanied by other 
corroborative testimony. I answer in the negative. The opin- 
ion here expressed, however, is not applicable to infantile syph- 
ilis. In new-born children it is extremely rare to find .any 
cutaneous eruption, or any affection of the mucous membrane, 
as of the nose or mouth, except those of a venereal character. 
This fact will receive further consideration, under the head of 
Infantile Syphilis, in the concluding chapter of this work. 

Tubercles, ulcerations, and other consecutive lesions that 
attack the mouth and throat, furnish the strongest evidence of 
the contamination of the blood. They are, for the most part, 
more easily managed than analogous affections that appear 
upon the cutaneous tissue. In some instances, however, they 
prove the most obstinate morbid conditions we attempt to 
remedy. In still other cases, when we think the parts are 
nearly well, and we are anticipating the time as at hand when 
the treatment can be discontinued, the diseased action will be 
kindled up anew, and we are driven to straits as to what can be 
done next. 

The Tongue. — The true syphilitic ulcers that attack the 
tongue generally penetrate quite deeply into its substance. 
Their edges are sharply defined, excavated, and hard to the 
touch. Their occurrence is much less frequent than the more 
superficial ulcerations of the tonsils and pharynx. They are 
sometimes mistaken for cancer even by experienced surgeons. 
Several cases are mentioned in Guy's Hospital Reports ; * one, 
in particular, where a venereal ulcer of the tongue was pro- 
nounced by several eminent surgeons to be cancer. It was 
touched with caustic, and the iodide of potassium administered 

♦Vol. VII., p. 345. 



372 GONORRHOEA AND SYPHILIS. 

internally for six months, by which time the ulcer was healed 
perfectly. The patient finally acknowledged that he had the 
syphilitic taint ; and the presence of coppery stains, detected 
upon the legs, confirmed the truth of his confession. 

In some patients, of peculiar idiosyncrasy, the use of the 
iodide of potassium, for a few days only, has been known to 
create swelling, soreness, and lumps upon the tongue, closely 
resembling true syphilitic tubercles. These conditions of the 
organ will generally subside immediately on the withdrawal of 
the medicine. 1 have known the presence of artificial teeth 
give rise to injuries of the tongue, which, judging from appear- 
ances presented by the member, apart from all other considera- 
tions, could not be distinguished from venereal accidents. I 
have seen two such instances within a year, and have met with 
others in the course of my practice. The individuals have 
usually been pale, delicate, dyspeptic females. In the two last 
cases to which I have alluded the edges of the tongue were 
ulcerated in several places. Both patients were married women. 
Both knew that their husbands had suffered from syphilis in 
former days, and both entertained an abiding fear that their 
lingual difficulty was due to the ancient delinquency of their 
recreant lords. 

The sides of the tongue are sometimes affected with small 
ulcers, having well-marked indurated edges, as a consequence 
of long-continued attrition against the sharp fragment of a 
decayed tooth. These sores bear a close resemblance to syph- 
ilitic ulcers occupying the same localities. Their occurrence 
demonstrates and enforces the importance of always ascertain- 
ing, by careful examination, the state of the teeth before we 
decide upon the character of the lesion thus situated. 

The internal use of mercury will sometimes occasion super- 
ficial ulcerations upon the tongue, or even severe glossitis, while 
the gums and salivary glands remain undisturbed by the medi- 
cine. A knowledge of the entire history of the case and its 
treatment will enable the surgeon to judge of the precise 
nature of these abnormal conditions, and to determine whether 
they are mercurial or syphilitic. 

The most frequent syphilitic affections of the tongue consist 
in superficial abrasions, of various extent and shape, and 
situated on the dorsum, among the circumvallate papilla?. 



ULCERS ON THE TONGUE. 373 

They do not appear to extend much, if any, deeper than the 
base of these papillae. The diseased surface is of a fiery red 
color, if the epithelium has been removed ; but sometimes this 
delicate covering is only partially detached, and may be seen 
rolled up into minute, loosened granules, and resting on the 
excoriated organ, giving it a mixed color of white and red, or 
perhaps yellowish white. 

Another lingual trouble, of venereal origin, is occasionally 
met with. I refer to sinuous fissures, which form on the margin 
or dorsum. They are of various depths. Sometimes they are 
mere superficial cracks ; sometimes they penetrate two or three 
lines, and exhibit irregular, ulcerated edges. In other in- 
stances no ulceration can be detected. The parts have very 
much the appearance of a small incised wound made by a 
sharp cutting instrument. This breach of continuity is fre- 
quently associated with tubercles in some portion of the buccal 
cavity ; but it may be the only specific symptom complained of. 
It is, in most cases, a source of no little annoyance to the indi- 
vidual, who can neither eat nor converse with comfort or free- 
dom. I have at this time under treatment a young man who 
had, a year or two since, constitutional syphilis, and has now 
several rhagades, or clefts, running parallel with each other 
across the tongue, on both sides, opposite the molar teeth. 
They have existed for more than ten months. The patient has 
no other venereal manifestation. The chlorate of potash has 
proved particularly beneficial in this case. 

When my attention was first directed to these sulci, I could 
scarcely persuade myself that they were syphilitic, but sus- 
pected they were caused by friction of the tongue against the 
teeth in some patients, and in others, who used tobacco, I 
attributed them to its influence. The affection is occasion- 
ally attended with a slight oozing of blood from the diseased 
surfaces. 

Treatment. — These fissures are often difficult to cure. The 
ulcerative process extends farther than might appear from slight 
inspection, and I have known this complaint to resist every 
remedial appliance for several months. The solid nitrate of 
silver, used daily or every other day, will sometimes cause the 
ulcerated walls to close up and heal kindly in a very short 
32 



374 GONORRHCEA AND SYPHILIS. 

time. In other instances, its employment is productive of no 
benefit. The chlorate of potash, both as a gargle and internally, 
is generally useful ; so also is the compound tincture of iodine 
brushed over the parts two or three times each day. 

Sometimes the patient complains of a constant dull pain in 
the part. In such cases the following lotion may be employed 
several times during the day, by means of a small camel's hair 
pencil : — 

R. Extracti Opii Aquosi, gr. vj. 

Aquae Ferventis, § iij. 

M. Cola, — et adde, 

Mellis Communis, 5 ij. 

Tincturae Myrrhae, . . • ., . 5 vj. 

The undiluted tincture of myrrh, the compound tincture 
of lavender, the aromatic wine, with tannin and opium, a 
weak solution of the potassio-tartrate of iron, may all be em- 
ployed. If the complaint show no disposition to progress 
towards a cure under the influence of one of these topical 
remedies, another and another must be experimented with, 
until a favorable effect is realized. 

Allusion has been made to the fact that nearly all the syph- 
ilitic lesions of the skin have their analogies in the mucous 
membranes ; and, accordingly, in addition to the phenomena 
already specified as invading the mouth, we find the deep, ex- 
cavated ulcer, the inflammatory ulcer, the sloughing ulcer, the 
ragged nicer, the chronic ulcer, the creeping serpiginous and 
superficial ulcer ; all which may attack any part within the 
buccal cavity, as the uvula, the fauces, the tonsils, and the 
pharynx. The ulcers that appear upon the palatine vault, or on 
the fauces or pharynx, do not ordinarily penetrate these parts 
to any great extent ; those that come upon the tonsils eat their 
way through these glands in a very irregular manner, and cut 
out excavations of all depths and- sizes. 

Sloughing Ulcerations — are among the most formidable 
accidents that seize upon the mucous membrane of the mouth 
and throat, especially when seated upon the posterior walls of 
the pharynx. These ulcerations may form either in the sec- 
ondary or tertiary period of syphilis. Their disposition is, 



ULCERS ON THE TONGUE. 375 

invariably, to extend in all directions. Downwards, they pro- 
ceed towards the oesophagus and rima glottidis, always inter- 
fering with the act of swallowing, and, in some instances, 
exciting the most agonizing dyspnoea. Backwards, the ulcera- 
tive process may attack the bodies of the cervical vertebrae, 
and induce caries ; and in its upward course, it will advance 
toward the nares, involving the fauces, tonsils, and the soft 
palate. In some cases the morbid action, which has its origin 
in the mouth or throat, produces closure of the Eustachian 
tube, and, extending along its whole course, reaches the lining 
membrane of the tympanum, which becomes inflamed, and the 
result is irremediable loss of hearing. I have, while writing 
this, a patient under treatment for tertiary syphilis ; and 
among the hydra-headed symptoms that every now and then 
arise in the case is ulceration, which commenced at the back 
of the pharynx and subsequently spread to the adjacent parts. 
For about a year past the primary seat of the ulceration has 
remained sound ; but the disease still lingers in the parts 
above. The left Eustachian tube is implicated ; and loss of 
hearing in the corresponding ear has existed for more than 
six months. It is a well-marked case of syphilitic deafness. 
The patient is a young female, and has suffered from specific 
symptoms of one kind and another for more than six years, 
with an occasional truce of a few weeks. 

Secondary sloughing ulceration of the pharynx sometimes 
gives rise to a catenation and severity of symptoms which it 
is not in the power of human language to describe. In these 
extraordinary cases the patient is doomed to suffer intensely 
from constitutional irritation. The pulse sinks to an extreme 
degree of feebleness, the skin becomes hot and dry, there is 
unceasing pain in the throat and chest, with a sensation of im- 
pending suffocation, which any attempt at deglutition exasper- 
ates, and renders still more alarming. The morbid process, as 
already stated, extends in every direction, involving the tissues 
in one continuous, ulcerating surface. Among the important 
structures thus engaged are the epiglottis and the larynx ; and 
the patient is then tormented with fits of coughing, accom- 
panied by a constant secretion of thick, viscid saliva, which ad- 
heres firmly to the throat ; expectoration becomes difficult ; so 
much so that he thrusts his fingers into his mouth to pull 



376 GONORRH(EA AND SYPHILIS. 

away the ropy mass, and thus save himself from suffocation. 
By day there is a ceaseless inclination, but without the ability, 
to vomit ; and during the night the throat is clogged every few 
minutes by the incessant discharge, and he is, consequently, not 
only deprived of sleep, but thrown into great distress. The 
power of speech becomes more and more feeble, until, at length, 
complete aphonia supervenes. Day after day the symptoms 
assume a more desperate character, until the sufferings of the 
miserable victim finally become terrific. He can neither eat, 
drink, nor sleep, and he falls into a condition from which no 
human skill can rescue him. I have seen a few instances of 
this description, the last of which occurred about two years 
since in this city. The agony, bodily and mental, in the case, 
was so unremitting and dreadful, that the patient often begged 
for chloroform to put an end to his existence. Reduced nearly 
to a skeleton, he sank at last under the weight of his accumu- 
lated miseries. 

Those of my readers who have had an opportunity to ob- 
serve from day to day the symptoms of an individual strug- 
gling with the variety of pharyngeal ulceration, the prominent 
effects produced by which are here given, will bear witness 
that the description is not couched in the language of hyper- 
bole. Thirty or forty years ago such cases were far more 
common among venereal patients than they have been since a 
more simple and rational treatment has characterized medical 
practice. 

Treatment. — This resolves itself into local and general, as is 
the fact in nearly all venereal affections. 

In the diversified syphilitic ulcerations and other morbid con- 
ditions of the mouth and throat, topical remedies, although for 
the most part of secondary importance, are nevertheless of 
great value ; and the patient will not be content without re- 
course to them, nor should the surgeon. In the selection of the 
most appropriate local means, by which to establish and keep up 
healthy action in the affection now before us, the professional 
attendant will often find his highest skill put to a severe test. 

Nitric Acid. — For sloughing ulcers the concentrated 
nitric. acid is justly regarded as an excellent topical remedy. 



ULCERS ON THE TONGUE. 377 

It is suited to a majority of such sores. If the surgeon de- 
sire to touch it upon the tonsils, fauces or any part nearer to 
the oral aperture, a small bit of sponge, secured to whalebone 
and slightly wet with the acid, should be used. The utmost 
care must be observed not to have any dripping of the fluid. 
After moistening the sponge, it will be well to squeeze it 
against the cup or gallipot, so that there shall be no danger of 
a particle of the caustic falling where it is not wanted. The 
medicated sponge is to be carried forward directly against the 
ulcer, and withdrawn as quickly as possible. A tumbler-full 
of warm water should be at hand, that the patient may use it 
as a gargle at once. The surface touched with the acid will 
now present a white aspect, which is evidence that it has done 
proper execution. After one or two trials, the young surgeon 
will feel at ease in performing this not unimportant operation, 
which he should always take a pride in doing well. If the 
posterior surface of the pharynx be the seat of disease, 
and if the application of the escharotic be made there, the 
operation is not so simple as when performed on the parts just 
spoken of. This is true at least so far as relates to the patient. 
In spite of all precaution it will sometimes happen that the 
dense vapor generated while the acid is being applied will ex^ 
cite exceedingly unpleasant symptoms. "While the surgeon 
depresses and confines the tongue with a spatula or spoon, for 
the purpose of gaining free access to the distant walls of the 
pharynx, the patient cannot always have perfect control of 
the respiratory apparatus. The head is inclined backward, and 
the epiglottis and its immediate dependencies are not in a nor- 
mal position. The heavy fumes of the acid may gravitate 
upon these parts, which may be instantly stimulated to a most 
violent spasmodic action, threatening the life of the patient. 
Some writers give us the caution to wait until the fumes of 
the acid pass off from the sponge before applying it ; but if it 
be merely damp, there is still a liability to serious mischief 
from particles of vapor lodging where they ought not. I speak 
from experience. I once had under my care a young medical 
gentleman with extensive ulceration upon the pharynx, to which 
I applied the acid with a probang, the sponge being not so large 
as a common chestnut. This was done every second or third 
32* 



378 GONORRHOEA AND SYPHILIS. 

day, for two or three weeks, care being always taken to have the 
sponge acidulated in the slightest manner possible. The fumes 
at length occasioned a good deal of irritation, coughing, and 
distress in breathing. At each successive trial these unpleasant 
effects increased, until it became impracticable to use this topical 
remedy, although it exerted a favorable influence upon the 
ulceration. The last application was made with great prudence 
and gentleness, but it instantly produced intense agony and 
alarm. For a moment it almost seemed that the patient must 
expire. I am sure these untoward effects were caused by the 
vapor, and not by any excess of the acid. The compound tinc- 
ture of Benzoin was substituted, and the fruits of its good service 
in maintaining healthy granulations upon the ulcerated parts 
were soon manifest. It was applied thrice daily for three or 
four days ; subsequently, only twice a day, and by the patient 
himself. Where it is proposed to touch the nitric acid to the 
posterior surface of the pharynx, I think it should be diluted 
with two or three times its quantity of water. The numerous 
trials, however, which I have now made with the Benzoin tincture, 
and the prompt and beneficial results that have uniformly been 
obtained, have weaned me from the acid as a topical remedy in 
the disease under consideration. The unmitigated harshness 
of the latter substance, and the danger invariably attending its 
most cautious employment, will deter me from using it upon 
the pharynx. The Benzoin is about as safe as so much cold 
water, and, as a curative agent in such cases, I know not where 
to look for its superior. The compound tincture of Benzoin has 
lost none of its ancient prestige. It was formerly known as 
Traumatic Balsam, Wade's Balsam, Friar's Balsam, etc. In its 
immediate local effect it is moderately stimulating, and as a 
reparative to ordinary sloughing ulcers, wherever situated, I 
regard it as possessing great merit. It was once a popular ap- 
plication for recent wounds, — to which, it is scarcely necessary to 
say, it is injurious, as it would excite too much inflammation, 
and thus prevent union by the first intention. As a local appli- 
cation to the pharynx it can be intrusted to the patient's man- 
agement with safety. If a few drops happen to be swallowed 
no harm can result. 



ULCERS ON i^HE TONGUE. 379 

Case. — Sloughing ulcer of th&pharynx — compound tincture 
of Benzoin employed — cure. 

April 7, 1856. The patient was a married lady, of education 
and high social position, aged 28 years. She was extremely 
pallid, thin in flesh, and dejected in spirit?. Four years ago she 
received the primary inoculation from her husband, who lived 
everywhere. She had secondary eruptions and ulcerations more 
or less upon the skin for three years before I saw her. When 
she first consulted me, there was inflammation and hypertrophy 
of the fauces, and a few vegetations of the size of kernels of 
wheat had sprouted upon them. The posterior surface of the 
pharynx had been the seat of similar growths, except, as she re- 
ported, that the latter had a larger base than those on the 
fauces. They were, doubtless, broad, flattened, mucous tuber- 
cles. A few slender excrescences were also hanging from 
the velum. At the date above specified an extensive ulcer occu- 
pied the pharynx, giving much discomfort and pain, and occa- 
sioning serious impediment in deglutition, especially when she 
attempted to swallow solid food. The skin was free from disease, 
although numerous cicatrices, occasioned by former ulcerations, 
were imprinted upon the extremities. 

Mercury had been administered at different times ; but there 
was no evidence that ptyalism had ever been induced. As a 
local appliance to the pharynx, the compound tincture of Ben- 
zoin was selected. At first it was used twice daily, by means of 
a bit of sponge secured to a stick. In two days the ulcer 
acquired a decided reparative action. In ten days the patient, 
who resided some thirty miles from the city, was allowed to 
return home, with instructions to use the tincture two or three 
times each day, — which she did. She complained of very little 
inconvenience from the immediate impression of the tincture. 
In a few weeks the ulcer was healed. For the removal of the 
abnormal growths upon the fauces a few. touches with the con- 
centrated nitric acid proved sufficient. 

The administration of the potassio-tartrate of iron in the 
infusion of gentian, associated or alternated with the iodide of 
potassium ; opium to quiet any occasional pain and irritability 
of the system, and to secure refreshing sleep by night ; quinine, 
decoction of sarsaparilla, decoction of yellow dock root, gener- 



380 GONOBRHCEA 4ND SYPHILIS. 

ous diet, wine, porter, warm loathing, and the pure air of the 
country, constituted the general therapeutics in the above case. 
No mercury was employed^; e ither locally or otherwise, whilst the 
patient was under my car*}. She improved gradually, and with- 
out experiencing any Relapse, until she acquired a tolerable 
measure of health, although by no means equal to that of former 
days. 

A. few^ months after the date given in the preceding instance, 
another of similar character came under my charge, although 
the ulceration did not occupy the pharynx. 

September 7, 1856. — Patient Mrs. B., aged 32 years. Twice 
married. Infected with primary disease six years ago by her 
first husband ; knows she had chancre. Reports that she never 
had any cutaneous eruption, nor other abnormal condition of 
the skin, except what was then apparent. Large, dirty yellow 
blotches covered most of the integument of both thighs. The 
discoloration gave no inconvenience, and never had. It had 
existed, according to the patient, nearly four years. No marks 
of papules, pustules, or ulcers, to be discovered on any portion of 
the skin. The complexion, originally fair, had now a mottled 
appearance ; integument, generally, felt harsh and dry ; and a 
furfuraceous exfoliation of the epiderma of the upper extrem- 
ities, between the shoulders, upon the chest and face, presented 
itself, although daily ablution was practised. The patient was 
a short, stout-built woman, but complained of great lassitude, 
pains in the limbs and head, loss of appetite, and extreme diffi- 
culty of deglutition. She was unable to swallow a particle of 
solid food, and had lost eighteen pounds of flesh in six months. 
The vocal apparatus was so mutilated that she could scarcely 
enunciate her words so as to be understood. She stated that 
she had taken large quantities of mercury at different times 
under the direction of physicians, and had suffered from saliva- 
tion. Upon examination of the mouth, a large portion of the 
fauces, the tonsils, and soft palate was found to have been de- 
stroyed, and the buccal cavity presented a hideous look. How 
much of this extensive destruction was due to mercurial 
action, and how much to the syphilitic poison, could not be deter- 
mined ; but the fact that the skin had never been disturbed by 



ULCERS ON THE TONGUE. 38X 

any papular, tubercular, or other morbid condition of a serious 
character, led me to doubt whether all the mischief which had 
happened within the mouth was chargeable to the latter cause. 

The constitutional treatment in this case was almost precisely 
like that adopted in the preceding. The only topical remedy to 
the ulcerated remains of the palate and the fauces was the com- 
pound tincture of Benzoin. The employment of gargles was 
impracticable ; they could not be retained in the mouth. The 
moment the head was raised all fluids would descend into the 
oesophagus. The patient resided about an hour's ride from 
Boston. She reported herself from time to time. From the 
7th of September to the 1st of the following January, she gained 
in weight twenty-jive pounds, and at this latter period the dis- 
eased surfaces were healed. An ingenious artisan constructed 
a metallic palate, which the patient has worn nearly the whole 
time without inconvenience. She remains well, and eats, 
drinks, and converses without difficulty. 

The sponge or rag-swab employed for applying the tincture 
of Benzoin very soon becomes hard and unfit for use, but the 
patient can easily keep himself supplied with a fresh stock. 

My experience with the Benzoin is limited to old, atonic 
ulcers, and to secondary phagedenic or sloughing ulcers. In 
the treatment of primary phagedenic, chancrous sores, I 
should question its utility. For these the concentrated nitric 
acid or the saturated solution of potassio-tartrate of iron is to 
be preferred. 

Gargles. — In cases where the compound tincture of Benzoin 
is employed repeatedly during the day, it is seldom necessary to 
resort to gargles. In some instances, however, the latter are 
required ; and there are several formulae that prove beneficial in 
various kinds of ulcerations within the mouth. A solution of 
the chlorate of potash, of different degrees of strength, has 
already been sufficiently noticed. A decoction of the sophora 
tinctoria (wild indigo or indigo-weed) makes an effective gargle 
for aphthous and other ulcers of the mouth, whether syphilitic 
or mercurial. The bark of the root is the part to be steeped, in 
the proportion of one ounce to the pint of water. The oxymel 
of subacetate of copper, diluted with water, is another prepara- 



382 GONORRHCEA AND SYPHILIS. 

tion that will be found excellent. The following is the strength 
generally to be employed : — 

ft. Oxymellis Cupri Subacetatis, g ij 

Aqua? Fontana?, § vj. 

M. ft. gargarisma. To be used repeatedly during the day. 

Another : — 

ft- Decocti Cinchona? Corticis, § x. 

Acidi Hydrochlorici Diluti, 5 ij- 

M. ft. gargarisma. To be used two or three times a day. The mouth 
should be rinsed with warm water immediately afterwards. 

A mixture of cinchona and opium furnishes a valuable wash 
and gargle in all cases of sloughing ulcers within the mouth ; 
also where there is a disposition in the part to degenerate into 
a gangrenous condition, as is sometimes seen in the side of the 
cheek, the gums, etc. 

ft. Corticis Cinchonas Rubra?, . . . . . . . . . . 5 ij- 

Aqua?, §xij. M. 

Boil down to eight ounces, and add one scruple of the watery 
extract of opium. Filter. To be used ad libitum. 

If the under surface of the tongue be ulcerated, a small 
piece of English lint, soaked in weak chlorinated water, should 
be kept in contact with it. 

Constitutional Remedies. — The brief epitome of the gen- 
eral treatment pursued in the two* last cases reported, together 
with what has been advanced elsewhere in preceding pages, 
will, I trust, sufficiently indicate the views I entertain relative 
to the constitutional measures when sloughing ulcers exist in 
the mouth. The use of mercury, while the patient has the 
misfortune to be struggling with such an affection, seems wholly 
uncalled for, and, in a majority of cases, would be sadly disas- 
trous. He is sufficiently miserable without the hazard of be- 
coming still more so by its action ; and in such a juncture the 
practitioner should study to spare the poor victim any exposure 
to causes that might provoke a serious aggravation of symptoms. 
Mercury, therefore, should be withholden. But when the pa- 



ULCERS ON THE TONGUE. 383 

tient comes to us with other venereal symptoms, which have 
been mentioned as appearing within the mouth and throat, and 
we are sure they are such, our inquiry should be, when we are 
about to prescribe, whether mercurials have been administered 
and have had a fair trial. If they have not, and if the consti- 
tution of the patient appears to be in a favorable condition, so 
that he can bear the remedy with safety, then the bichloride, to 
the amount of one-eighth or one-tenth of a grain, morning and 
evening, may be prescribed in combination with tonics, sudo- 
rifics, and a generous diet. The effect of mercury, even when 
administered in small quantities, must be carefully watched ; 
otherwise a sore, which is not of a sloughing nature, may 
become so, especially if it be located on- the soft palate, or the 
inside of the cheek. If mercury in any form has been given, 
the iodide of potassium should be our chief reliance ; for it will 
probably turn out that the case is either far advanced in the 
secondary period, or is what syphilographers style in the transi- 
tion-stage between secondary and tertiary syphilis. At any 
rate, if mercury has been tried, and has failed to cure, the 
potassium will be well adapted to the case. It can be alter- 
nated, if the physician choose, with large quantities of the 
potass io- tartrate of iron ; that is, one of these preparations 
may be given for two or three weeks, and then the other. 
Nitric acid, quinine, and sarsaparilla are to be administered in 
some cases as auxiliaries. 

In regard to local measures which may claim confidence, the 
formulae inserted under the head of sloughing ulcers will fur- 
nish the mind of the judicious medical attendant with ample 
resources from which to make appropriate selections, according 
to the different varieties and phases which the ulcerations may 
present. If the consecutive phenomena now under considera- 
tion are seen at an early period, they can usually be subdued 
without difficulty, and the probability of their reappearance in 
their original severity is not very great, even if they return at 
all. For the twofold purpose, however, of guarding the sys- 
tem as far as possible against a recurrence of these symptoms, 
and of protecting it against any tertiary phenomena, the potas- 
sium and potassio-tartrate of iron should be continued for four 
or five months in moderate quantities, and with occasional 
intermissions of one or two weeks. 



384 GONORRHOEA AND SYPHILIS. 

If a long period has intervened since the advent of these 
secondary lesions, and if the constitution has become, as it 
were, saturated with the syphilitic poison r which may be known 
by the concomitant symptoms on the skin, by nocturnal rheu- 
matic pains in the bones or joints, by the falling out of the 
hair, by the pale, emaciated, and shrivelled features, by the soft, 
adynamic state of the muscles, and by the serious deterioration 
of the general health, — all which are indications that tertiary 
affections are about to appear, — then our anticipations in the case 
will be any thing but favorable. However judicious the line 
of treatment, and however successful for the time being, the 
disease will manifest a viability not inherent in any other mal- 
ady ; and the chances are that, before many months have 
elapsed, the patient will again present himself with the neces- 
sity upon him of once more testing our skill ; or, what is quite 
as possible, some professional neighbor may be called upon to 
occupy our post. 

Larynx. — When a patient has for a long period suffered 
from constitutional syphilis, he is liable to become affected with 
various morbid conditions of the larynx. The local affection 
may be simply a catarrhal congestion, or it may advance to an 
intense inflammatory action, resulting in extensive ulceration 
and consequent loss of substance. There is copious expectora- 
tion of foetid purulent matter, mixed with blood ; and if the 
morbid action is not arrested at an early period, the glottis, the 
cricoid, and other cartilages, are either totally destroyed, or, as 
has been noticed la some fatal cases, are found in a state of 
caries and necrosis. 

In some instances soft, whitish, irregular tubercles, or condy- 
lomata, are formed upon the surface, together with oedema and 
gradual thickening of the mucous and sub-mucous tissues, in- 
volving more or less the inter-cartilaginous portions of the vocal 
cords, and producing hoarseness, cough, stridulous breathing, 
dysphonia, or even total loss of voice. Under these abnormal 
circumstances, as may be seen with the laryngoscope, the diame- 
ter of the laryngeal canal is very much diminished by the tume- 
faction of its walls. This narrowing, or contraction, is termed 
syphilitic stenosis, and is seldom influenced by the use of any 
local remedies. Occasionally the application of nitrate of sil- 



ULCERS ON THE TONGUE. 385 

ver, or a weak solution of the bichloride of mercury (one grain 
to the ounce) has proved efficacious ; and in one instance which 
recently occurred in the London Hospital, under the care of 
Mr. McKenzie, great improvement appeared to result from a 
" pulverized solution " of perchloride of iron, which the patient 
inhaled. The strength of the solution was in the proportion of 
five grains to the ounce.* 

The iodide of potassium is the most promising constitutional 
agent for subduing these laryngeal phenomena, which belong 
partly to the secondary and partly to the tertiary group of 
symptoms. 

* London Medical Times and Gazette, March 5, 1864, p. 253. 

33 



CHAPTER XXXIY. 

SYPHILITIC DISEASES OF THE NOSTRILS AND NASAL 

FOSSAE. 

These accidents require but a brief special notice. They 
usually appear subsequently to the affections which implicate 
the tongue and buccal mucous lining. In some instances they 
can be properly reckoned among the more tardy secondary 
symptoms ; at other times they are to be included in the ter- 
tiary group. 

The ulcers that form within the nose, under the influence of 
the syphilitic diathesis, present two varieties ; the first being 
superficial, and confined to the mucous surface ; the other pen- 
etrating more profoundly, and destroying not only more or 
less of the soft parts, but also attacking and demolishing the 
cartilaginous and osseous structures, and producing conse- 
quent irreparable deformity of the features, impairment of 
speech, and abolition of the sense of smell. These effects 
are not unfrequently witnessed in patients who, either from 
neglect or necessity, have failed to receive proper medical 
attention. 

The symptoms of morbid action are usually developed in a 
very gradual manner, and, in many instances, exist for several 
months before they excite alarm or even suspicion. At first the 
patient discovers a little tenderness of the Schneiderian mem- 
brane, with a sensation of soreness within the nasal passages, 
and a slight impediment to the free transit of air in the process 
of respiration. At this early stage there is no fixed pain in the 
parts, and the individual merely has occasion to employ the 
handkerchief, and make a little extra effort to dislodge any 
accumulations which he thinks may have been secreted in con- 
sequence of a cold. Sometimes no abnormal exudation occurs 

(386) 



, NOSTRILS AND NASAL FOSSAE. 387 

until several weeks have passed, when ulceration takes place in 
some portions of the mucous tissue. The discharge is small in 
quantity, and consists in a heterogeneous compound of blood, 
pus, epithelium, and debris of the parts that have been de- 
stroyed. It exhales a most offensive odor. Sometimes it con- 
cretes upon the ulcer, and is dislodged in the form of a dark, 
dry, thick scab. The natural tones of the voice become altered 
as the morbid process extends, and the patient, perceiving that 
what he regarded as a cold has taken a singular turn, at length 
applies for advice. This is the simplest and most superficial 
form of ulceration which occurs within the nasal apparatus. 
It belongs to the secondary accidents, and is sometimes co- 
existent with cutaneous affections of the same chronological 
epoch in the history of the syphilitic disease. 

A favorable prognosis may usually be entertained. With or- 
dinary skill on the part of the practitioner, and prudence and 
care on the part of the patient, the affection above described 
may be healed in a short time. But when ulceration within 
any portion of the nasal organ appears as a tertiary symptom, 
our anticipations will be of a different complexion. The patient 
will probably survive this local affection ; but the chances are 
that the cartilages and bones of the nose will be destroyed to an 
extent that will result in a most repulsive deformity, and render 
him utterly wretched for life. 

The abnormal action is remarkable for the exceedingly slow 
rate of its progress. The soft parts may remain in a merely 
hypertrophied state for weeks and months without yielding any 
morbid exudation, and the complaint may appear to be nearly 
stationary. In time a slight but foetid discharge is noticed, 
containing perhaps small osseous fragments detached at dis- 
tant intervals from one of the turbinated bones, from the 
ethmoid or vomer. These facts will show, with sufficient plain- 
ness, that ostitis exists, with ulceration of the soft coverings of 
the bones. The two lesions often accompany each other ; and 
the medical practitioner who has had much experience will 
regard such a condition of things with profound apprehension. 
The disorder, as thus developed upon these parts, may continue 
its ravages for two, three, or four years, notwithstanding his 
unremitting and most judicious efforts, and terminate only with 
a total loss of the whole interior of the nose. The complaint 



388 GONORRHOEA AND SYPHILIS. . 

seems to die out, in such cases, because it has nothing to feed 
upon. 

Treatment. — If the ulceration be superficial, and appertain 
to the earlier period of constitutional disease, local remedies 
may be resorted to with a fair prospect of immediate and per- 
manent relief. Injections claim our first attention. A solution 
of chloride of soda, variously diluted with soft, warm water, 
will be likely to afford more benefit than any other local meas- 
ure. At whatever point of the nasal mucous lining the ulcer- 
ation is situated, the solution may be used with safety many 
times in the day. To be more definite as to the strength that 
should be employed, I will submit the following formula as 
suited to the generality of cases : — 

R. Solutionis Sodse Chloridi, 3 iv. 

Aquae Fontanse, . § vj. M. 

To be used as an injection. 

The black wash is excellent and is preferred by some sur- 
geons to all others. It should be thrown up the nostrils every 
two or three hours. The chloride of zinc, in the proportion of 
four or six grains to the ounce of rain-water, is likewise very 
beneficial as an injection. 

If the nasal affection belong to the tertiary period, involving 
the delicate osseous framework of the organ, the injections that 
have been mentioned will be required ; and I prefer them in the 
order given, especially if the patient be troubled with ozaena. 
Should the diseased action be concealed high up the fossae, or 
in the region of the posterior hares, injections even here will be 
of great utility, and the patient should be encouraged to employ 
them with persevering assiduity. 

Constitutional Treatment. — If the mucous membrane 
alone be the seat of chronic inflammation, and there be as yet 
no ulceration or other obvious phenomena connected with the 
nostrils, the bichloride of mercury to the amount of one-eighth 
of a grain each day, and as an auxiliary agent, may be pre- 
scribed, provided that the individual is otherwise in fair health, 
and has never been affected by the specific influence of any 
mercurial preparation. Chalybeates in some form, the iodide 
of potassium, and other tonics, will be appropriate for most 



NOSTRILS AND NASAL FOSSAE. 389 

patients who complain of this local trouble, which, in very 
many instances, is but the sure harbinger of a more profound 
mischief that awaits the ill-fated organ. 

If the periosteum and bones are involved, the constitutional 
treatment will form a difficult problem for the consideration of 
the wisest practitioner. The symptoms in these cases are so 
remote from the original specific lesion which gave them birth, 
that mercurials must be excluded from the calendar of thera- 
peutics ; for they would only augment existing evils. Indeed, 
there is reason to believe that caries and exfoliation of the nasal 
bones are not always produced by the exclusive agency of the 
syphilitic poison, even in venereal patients. In many instances 
these shocking results have been induced in part, if not wholly, 
by the previous injudicious administration of mercury. 

Of tertiary syphilitic affections of the nose I have met with a 
goodly number of cases. I have seen them most frequently in 
the foul wards of our public charitable hospitals, the final 
refuge of so many victims of both sexes, who are reduced to 
the last extremity of wretchedness. The facts I have gleaned 
in connection with this form of disease have almost brought the 
conviction to my mind that, in very many instances, it is but little 
benefited by any medicinal remedies. All the tissues that con- 
stitute the organ may continue for years to be the abode and 
the prey of the venereal element, while no other portion of the 
physical system is absolutely implicated. The external integ- 
ument of the nose, the mucous membrane, and the periosteum, 
yield up their substance little by little to the morbid encroach- 
ments ; and the fragile bones become denuded, perforated, and 
eroded by the same destructive process, which, whether any 
attempts are made to arrest it or not, seems to advance at about 
an equal pace. The work of demolition progresses without pain 
and with almost inconceivable sluggishness, showing itself at 
distant intervals in decrements of a solitary granule of bone, 
or in a microscopic relic of soft tissue, dislodged from the dis- 
eased locality, together with other effete matters. 

The exhibition of the iodide of potassium alternately with 
the potassio-tartrate of iron, a nutritious diet, residence in a 
wholesome atmosphere, and the inculcation of regular habits, 
constitute a code of treatment which should be recommended in 
this deplorable condition of the syphilitic patient. 
33* 



390 GONORRHOEA AND SYPHILIS. 

The mucous membrane of the ear, the eye, the genital ap- 
paratus, the anal region, etc., is obnoxious to secondary lesions. 
It would, however, be but a needless repetition to go into a 
separate consideration of these several varieties of local mani- 
festations. They all have a general similitude of type and 
development, and require no important modification of the 
constitutional or topical measures already enumerated. 



CHAPTER XXXV. 
SYPHILITIC IRITIS. 

This affection was formerly attributed to the physiological 
action of mercury, but is now known to be one of the mani- 
festations arising in consequence of the venereal contamina- 
tion, and to exist, in many instances, where mercury has con- 
stituted no part of the treatment for the cure of the original 
disease. The German oculists were the first to discover this 
fact. 

The disorder frequently arises in conjunction with secondary 
phenomena on the skin or mucous membranes, and must of 
itself, in such cases, be reckoned as a secondary accident. It 
sometimes, however, makes its appearance at a very late 
period, while the patient is afflicted with periosteal and other 
well-marked tertiary affections ; and, when thus associated, it 
is proper to regard it as a tertiary lesion. The distinction 
here given is somewhat important, especially in relation to 
treatment. The therapeutics adapted to the former group of 
symptoms may not be suited to the latter. For instance, 
cases of iritis, occurring while the skin is more or less covered 
with syphilitic papules or tubercles, may do well under the 
influence of mercurials ; whereas the same ophthalmic symp- 
tom, developed at a more advanced period of the specific dis- 
ease, and as a sort of tertiary vestige, would do better under the 
use of iodide of potassium and other tonics. 

The complaint may exhibit an acute or a chronic type from its 
earliest stage, or the chronic form may supervene upon the acute. 

The term " iritis, " as signifying a distinct malady, has been 
objected to by some eminent surgeons, because other structures 
besides the iris are implicated in the morbid processes. They 
regard the attack as a profound ophthalmia. 

Iridal inflammation may attack one eye or both at the same 
time. One of the earliest appreciable effects consequent upon 

(391) 



392 GONORRHOEA AND SYPHILIS. 

this morbid action is an impairment or even total loss of sight. 
This result is, in some instances, manifest within twenty-four 
hours from its commencement. A great change is wrought in 
the natural appearance of the eye, in consequence of the effu- 
sion of lymph into the anterior chamber and into the sub- 
stance of the iris. As the disease advances, this membrane is 
more or less concealed by a fibrinous deposit occurring in nod- 
ules or tubercles of a brownish tint, and collecting in greatest 
abundance near the pupillary margin, which is thickened and 
more or less corrugated or scalloped. In some instances, these 
tubercular excrescences become quite organized with ves- 
sels and degenerate into minute yellow abscesses. The latter 
frequently burst, and the matter settles at the bottom of the 
anterior chamber, constituting what is termed hypopium. The 
inflammatory process involves the whole parenchyma of the 
iris, the surface of which may sometimes be seen dotted with 
particles of extravasated blood. Adhesions are very liable to 
form at different points between the ciliary border of the iris 
and the capsule of the lens. They often acquire considerable 
firmness, and the liberation of the iris, by the employment of 
belladonna, is a work of no little difficulty. There is distor- 
tion of the normal figure of the eye, and a corresponding ir- 
regularity in the shape of the" pupil, in consequence of some 
portions of the iris being confined to the capsule, while other 
portions remain free. 

Occasionally, adhesions are formed between the whole cir- 
cular edge of the iris and the capsule, and what is called cap- 
sular cataract is the result. In April, 1854, I saw a case of 
this kind in a woman who had been under the care of a quack 
for secondary syphilis. The right eye had been attacked with 
iritis about one year before I saw it. The complaint lasted 
but a short time. The cornea was not injured. The pupil 
was contracted, and the iris apparently cemented to the cap- 
sule, which was covered with a dense fibrous membrane, and 
the function of the organ was totally destroyed. 

In some severe cases all the textures are involved, until 
finally the entire visual organ is converted into a mass of irrep- 
arable disease. When the attack occasions such phenomena, 
one may well question the propriety of regarding it simply as 
an iritis. 



SYPHILITIC IRITIS. 393 

Where the morbid action pursues its career rapidly, it is at- 
tended with pain, which occurs in paroxysms usually marked 
by their greatest severity during the hours of night. But if 
it be chronic from the commencement, it is rarely attended 
with much suffering. In some instances it is so insidious and 
gentle in its approach and development, that the individual 
may lose the use of the eye unconsciously, and before he is 
aware of any abnormal condition of the organ ; especially is 
this true if the patient be engaged in some employment re- 
quiring no special exercise of accurate vision. Now and then 
the complaint will disappear spontaneously without the use 
of remedial means from the surgeon. 

Although iritis may be subdued, and the organ restored to 
its natural appearance and functions, there is for a long time 
great liability to relapse. 

In the month of December, a few years since, a patient 
under my care for consecutive papular eruption, had an attack 
of iritis, in consequence of an exposure of several hours, 
which he spent in riding in an open vehicle, on a cold after- 
noon. The ride was one of pleasure, and was taken contrary 
to advice. The patient was a stalwart, daring man, of great 
natural powers of endurance, and his general health was tol- 
erably good at the time. But, as the result of his imprudence 
on this occasion, a severe inflammation of the right eye com- 
menced on the following day. For some weeks he had been 
taking the bichloride of mercury. This was now laid aside. 
A saline cathartic was prescribed ; after the operation of 
which, the patient was put upon the use of Ricord's pill of the 
proto-iodide of mercury, and the gums kept tender. For more 
than two weeks the ophthalmia was acute and painful. For 
the relief of the latter symptom fomentations of popy-water 
were directed, and proved entirely adequate. The malady 
became chronic and intermittent. Vision was nearly lost and 
restored several times during a period of six months. The 
eye finally regained its natural state. 

Diagnosis. — The differences between the syphilitic variety 
of ophthalmia and the arthritic or strumous form, are not suf- 
ficiently marked to constitute a rational basis for diagnosis. 
The medical attendant can rely with safety only on a true his- 



894 GONORRHOEA AND SYPHILIS. 

tory of the antecedents and the concomitants of this local 
trouble. 

Generally speaking, it may be stated that the deviation from 
the normal color of the iris, loss of its brilliancy, and stri- 
ated appearance, are more observable than in the non-specific 
varieties of the complaint. The capillaries exhibit a greater 
disposition to deposit lymph, and the pupil is more irregular 
and turbid, than in the rheumatic or strumous form of the 
disease. 

Slight cases of corneitis may be mistaken for iritis. In se- 
vere and aggravated instances of the former, the opacity and 
vascular excitement, conspicuous in the superficial structure, 
almost exclude the possibility of mistake ; but where the in- 
flammation of the cornea is mild, a mere dulness of this mem- 
brane takes place, closely resembling, on slight inspection, 
dulness of the iris. But, on a more careful and exact ex- 
amination, the medical observer will perceive, from every 
available point of view, that in iritis the loss of brilliancy seems 
to be deep-seated and uniform. In inflammation of the cornea 
the haziness is seen to be superficial ; and in most instances 
some portion of the corneal texture remains transparent, and 
through this the iris may be examined. If the pupillary mo- 
tions are found to be active, — dilatation and contraction being 
rapid, — there is satisfactory proof that the iris is sound. 

Ricord considers that the great peculiarity that separates 
this form of iritis from arthritic inflammation of the same part 
is the eruption which, in the syphilitic variety, takes place 
upon the iris, and which, he believes, bears as great an anal- 
ogy to the cutaneous eruption as the anatomical differences 
of the two regions permit; that is, if papules exist on the skin, 
they will be found on the iris ; and if a vesicular eruption be 
present on the former, true vesicles will be detected on the 
latter, and so on. That these analogies usually prevail, I will 
not take it upon me to doubt ; but will add that I have re- 
cently met with two instances in which there was no venereal 
eruption, although there had been only a few months previ- 
ously. In one of these the mucous membrane of the mouth 
was affected with secondary lesions simultaneously with the 
iritis. The other was accompanied by tertiary manifestations 
in the joints, the periosteum, etc., and the iritis was of a sub- 



SYPHILITIC IRITIS. 395 

acute type, and of which the patient suffered several relapses. 
At my request, Dr. H. W. Williams, of this city, saw the case 
in consultation. A tonic course of treatment, without mer- 
cury, was pursued, and the organ was finally restored to a 
healthy state. The patient had never taken any mercurial 
with a view to cure the ocular disease. 

Treatment. — For the removal of this local complaint, the 
mercurial treatment has for many years been regarded as "the 
sheet anchor," by the great mass of practitioners. The sub- 
muriate is the form usually preferred. The subjoined formula 
is perhaps as appropriate as any that can be selected in cases 
where the medical attendant has decided upon its employment. 
But no fixed rule can be laid down : — 

R. Pulveris Opii, . gr. xv. 

Hydrargyri Chloridi Mitis, 5 iss. M. 

Ft. pil. No. lx. 
Dose. — One pill thrice daily. 

As the disease yields, the pills may be taken less frequently. 
As soon as the mouth or breath indicates that ptyalism is about 
to set in, the quantity of mercury should be diminished, and 
every caution taken not to induce salivation. The remedy 
should be continued in quantities just sufficient to maintain a 
preternatural redness of the gums, and no more. 

In some cases, where the individual is in tolerable health, 
and the local inflammation is very severe, the application of a 
few leeches, and the employment of a brisk purgative, before 
commencing with any mercurial, will be advisable. But ordi- 
narily such preparatory measures will not be demanded. The 
calomel may be prescribed at once. Some surgeons prefer to 
combine it with the extract of hyoscyamus, for the reason that 
the opium may have a tendency to favor the contraction of the 
pupil. 

The utmost vigilance will be requisite to keep the pupil 
dilated, otherwise permanent adhesion of the iris to the cap- 
sule of the lens may take place. The extract of belladonna 
should be smeared freely over the eyebrow and forehead, two 
or three times in the twenty-four hours, throughout every stage 



396 GONORRHOEA AND SYPHILIS. 

of the complaint ; or, what is perhaps still better, the extract 
may be dissolved in the proportion of one drachm to eight 
ounces of rain-water, and applied over the eye by means of a 
fold of English lint. Atropia will exert the same favorable 
influence on the structures, and will likewise assuage any orbi- 
tar or frontal pains. It acts more rapidly, and is more con- 
venient and cleanly for external use, than the extract, and is 
now employed by many surgeons as a substitute for it. A sin- 
gle drop of a solution, made by dissolving two grains of the 
atropia in three ounces of distilled water by means of three or 
four drops of acetic acid, is to be applied to the inner surface 
of the lower lid. 

Ricord's formula for iritis is the following : — , 

Jft. Extracti Opii, gr. xv. 

Hydrargyri Proto-Iodidi, 

Extracti Cicutae, aa, gr. xlv. M. 

Ft. pil. No. Ix. 

One to be taken every night, and, in four or five days, two 
per diem, until the mouth becomes tender ; at the same time 
frictions to the base of the orbit, with equal parts of strong 
mercurial ointment and extract of belladonna, are to be used. 

The therapeutic operation of the mercurial, in suddenly 
arresting the abnormal exudation or tissue, is generally mani- 
fest at the moment it begins to display its disturbing, physiolog- 
ical properties upon the salivary apparatus. The circulating 
current is the medium through which the salutary agency is 
exerted. Mr. Addison, in his able work on scrofula and con- 
sumption, offers the following explanation relative to the bene- 
ficial action of mercury: "The principle upon which, in cases 
of internal disease, this is effected, before materially disturbing 
healthy functions, appears to be that the diseased growth lias 
the embryonic type, is the youngest or last formed, the teuder- 
est or most succulent, and, being abnormal, is the farthest 
removed from the accumulated conservative powers of the 
whole organism, so that it is the first to fade and sink away 
upon the presence of unsuitable conditions of alterative agents 
taken for the express purpose of its removal." These are 
ingenious thoughts ; but the fact that iritis can be cured with- 



SYPHILITIC IRITIS. 397 

out the administration of mercury would seem to cast a doubt 
upon the solution offered by the learned author as to the methodus 
cur audi of the potent mineral. And I cannot but regard the 
therapeutic problem as still remaining unsolved. 

After iritis is subdued, the iodide of potassium should be 
administered as an adjunct to the mercurial treatment, and 
also as a prophylactic measure against tertiary symptoms.. The 
potassium may likewise be advantageously prescribed at the 
same time with the mercury, in cases of iritis accompanied with 
severe neuralgic pains. Such are occasionally met with, where 
the ophthalmia comes on at a great remove from the primary 
lesion. The application to the affected organ of vapor-baths 
will be attended with favorable results, not only in subduing 
pain, but likewise in disgorging the vessels of the sclerotica 
and the palpebral conjunctiva, which very often are highly in- 
flamed. 

While the efficiency of mercury, in promoting the absorption 
of lymph and preventing its further deposition, is admitted, 
its power in controlling different forms and different stages of 
iritis has probably been overrated, and it has, without ques- 
tion, been administered too exclusively and too indiscriminately. 

If, in any given instance, there be a good share of constitu- 
tional vigor, and if the exudation retain the form of plastic 
lymph, or fibrine, the employment of mercury, as the chief 
curative agent, will afford more favorable results than any 
other. 

Should the patient be of a scrofulous diathesis, and his con- 
stitution feeble and broken down by a long and debilitating 
disease ; if the effusion of lymph be very abundant, and 
possess but few traces of organization, mercury will tend to 
increase the exudation instead of arresting it. It will act 
rather as a poison to the system than as an antidote to the 
complaint, and thus will aggravate the very condition of things 
which it was intended to remove, and which, in a less debili- 
tated frame, it would have cured.* So, also, if the malady be 
developed in conjunction with distinct tertiary symptoms, the 
individual will be in no condition to justify a resort to mercu- 
rial preparations. In all the exceptional cases and conditions 

*Vide London Lancet, March, 1855. — Mr. Critchett's Lecture. 

34 



398 GONORRHOEA AND SYPHILIS. 

here supposed, far better effects may be anticipated from the 
iodide of potassium, ferruginous tonics, nitric acid, and gener- 
ous living. 

If, from the constitutional circumstances of the patient, the 
physician cannot with prudence appeal to the well-known influ- 
ence of mercury, the oil of turpentine, as first recommended 
by Mr. Carmichael, of Dublin, will be found a valuable substi- 
tute. The salutary and prompt action of this medicine in 
iritis has' been attested by the most reliable authorities ; and 
I cannot take leave of the subject without inserting the for- 
mula relied upon by the distinguished Irish surgeon, even 
when the inflammation and pain and other symptoms are very 
severe : — 

R. Olei terebinthinae rectificati, § j. 

Vitellum unius ovi tere simul, et adde gradatim, . . 

Emulsionis amygdalarum, § iv. 

Syrupi corticis aurantii, §ij. 

Spiritus lavandulse composite, 3 iv. 

Olei cinnamomi, guttas, ij. vel. iv. 

Dose. — §j. three or four times daily. 

Some of the most eminent and practical ophthalmic surgeons 
now consider that mercury may, as a general rule, be safely 
dispensed with in the management of iritis, whether it exist in 
connection with syphilitic cachexia or not. Dr. Williams has 
reported a large number of cases successfully treated with the 
use of tonics, mydriatics, and the iodide of potassium, and 
without the administration of mercury in any form. 

In all instances, and especially those that assume a chronic 
type, great attention should be directed to the improvement of 
the general health. 

Heredito- Syphilitic Iritis. — Syphilitic children, from a few 
weeks to a few years old, are occasionally the subjects of iritis. 
They are generally feeble, cachectic, and troubled with other 
symptoms besides those which invade the eyes. Sometimes, 
however, the iridal complaint is the only abnormal condition 
which they actually exhibit. ' If the malady is recognized by 
the medical attendant at an early day it seldom acquires the 
severity which marks its course in the adult subject. Mr. Jon- 



SYPHILITIC IRITIS. 399 

athan Hutchinson, states that the female sex is far more subject 
to it than the male, and it makes its invasion at about the fifth 
month, oftener than at any other age of the child. 

Treatment. — Mercury, either in the form of the bichloride 
in solution, in doses of one-sixtieth of a grain of the salt twice 
a day, or one or two grains per day of the hydrargyrum cum 
creta, with generous diet and mild tonics, will be sufficient, so 
far as internal remedies are required. The application of 
atropia should be resorted to from the commencement, and 
repeated every day, or every other day, according to its appar- 
ent effect on the pupil. The strength of the solution may vary 
from a quarter of a grain to a grain in an ounce of distilled 
water. 

Besides iritis, the syphilitic virus produces other specific path- 
ological changes within the interior of the eye, to which we will 
briefly allude. It is well known that individuals laboring under 
constitutional syphilis frequently lose the power of vision, while 
no imperfection of the organ can be discovered by the ordinary 
methods of examination ; and it was not until the ophthalmo- 
scope was brought into practical use as a means of diagnosis, 
that the deeper tissues and humors of the eye could be ex- 
posed, and their true condition determined with accuracy. By 
means of this instrument it has been demonstrated that the 
choroid and hyaloid membranes, the retina, and vitreous humor, 
may, one or all, be in a diseased state for a long period, with 
only a trifling degree of pain, and unattended by congestion or 
other disturbance of the outer tunics of the eye ; and what is 
termed amaurosis syphilitica is dependent, according to Pro- 
fessor A. Yon Graefe, upon choroiditis or retinitis. 

Like iritis, the different forms of ocular disease here men- 
tioned usually, occur at a period which places them among the 
secondary phenomena ; and their treatment should be con- 
ducted on the same general principles as are suited to ordinary 
cases of iritis, — tonics and mercurials. The latter class of. 
remedies should be prescribed with a sparing hand, and the 
mode of their administration varied according to circumstances. 
Whether given internally or through the cutaneous surface, the 
results will be substantially the same. The latter method 



400 GONORRHOEA AND SYPHILIS. 

seems of late to be quite popular, and mercurial fumigations 
and mercurial inunctions are without any reasonable objections, 
if the parties interested choose to employ them ; although in 
private practice in this country, and among the better class of 
patients, the internal use of the medicine in question, will 
probably be preferred. 



CHAPTER XXXVI. 

TERTIARY SYPHILIS. 

Chiefly to the scientific and important investigations of 
Ricord are we indebted for the present classification of vene- 
real symptoms into three separate divisions, and for intima- 
tions that even a fourth group, the quaternary, may at some 
future day be defined and established in conformity with the 
laws which, if undisturbed, control the movements of the 
syphilitic poison in its mysterious wanderings through the 
human organization. The arrangement of these consecutive 
phenomena into distinct periods renders their study highly 
interesting and satisfactory to the student, while the practitioner 
is enabled to conduct the treatment on principles that lead 
to far greater success than that obtained in former times. 

The tertiary symptoms consist in certain changes that take 
place in the subcutaneous or submucous cellular tissue, in the 
testicles, in the fibrous and osseous textures, and in the deep- 
seated organs, as the lungs, the liver, the heart, the brain, the 
kidneys, etc. The serous membranes have seldom exhibited 
any syphilitic lesions. The affections, included under the name 
of gummy tubercles, or deep-seated tubercles, nodes, inflamma- 
tion of the periosteum, exostosis, and caries of the bones, belong 
to the division upon which we have now entered. 

By most writers on syphilis the fact is regarded as estab- 
lished that the tertiary manifestations are not transmissible by 
hereditary taint under their peculiar type, although, in conse- 
quence of a kind of degeneration or modification of the syph- 
ilitic virus, they are one of the most fruitful sources of scrofula. 
I am unable to perceive the propriety of applying the term scrof- 
ula to symptoms that have their origin in syphilis. It seems no 
more than fair and honest that syphilis should be permitted to 
retain undisturbed and full relationship to the multitudinous 
progeny which it begets. The relation is by blood ; and what 
34 * (401) 



402 GONORRHOEA AND SYPHILIS. 

the laws of nature have thus joined together, should not, and 
indeed cannot in truth, be sundered by. mere hypothetical 
speculations. Scrofula, also, has quite an amplitude of range 
among its own legitimate connections, and has no occasion to 
borrow of such a neighbor. To suppose that the matter of 
syphilis can be transformed into that of scrofula, would be to 
believe that the wolf can be changed into a lamb. ■ The wolf 
may mutilate or devour the lamb. In like manner syphilis 
may serve its victim. But neither wolf nor syphilis can lose its 
identity. Eicord speaks of a kind of degeneration or modifi- 
cation of the venereal virus, in consequence of which it is not 
transmissible as a syphilitic element, but is changed into an 
element for the genesis of scrofula. But this virus is subject 
to constant degenerations or changes. It is modified in its 
transit from the chancrous focus on the penis to its develop- 
ment on the fauces. The conditions or manifestations here 
are secondary, but they are syphilitic still, and not scrofulous. 
From the fauces the malady passes, we will suppose, to the nasal 
or other bones. Here is another modification, the tertiary ; but 
the manifestations or phenomena are still regarded as vene- 
real and not as those of scrofula. Thus far all writers agree. 
Now, suppose a child be born of a parent in whom the syph- 
ilitic virus is lodged, whether in the skin or the bones, or 
whether it shows itself in the form of deep-seated tubercles, 
and the child inherits the parental taint, why call it syphilis in 
the first case, and scrofula in the others ? 

Some years since, M. Lugol broached the doctrine that ter- 
tiary syphilis engendered scrofula. The idea is a specious 
one ; but facts to support it have not as yet been adduced to 
the satisfaction of the medical profession generally. Mr. Phil- 
lips, in his able treatise on scrofula, in commenting upon the 
question, " Does a syphilitic taint in the parent tend to pro- 
duce scrofula in the child ? " remarks : "I do not deny but 
that a scrofulous child may proceed from a syphilitic parent ; 
yet that is no proof that the child becomes scrofulous because 
the parent was syphilitic. And we have abundant proof that 
it is not scrofula, but syphilis, which under those circumstances 
is entailed upon the child. ... I know no well-proved 
fact, which can be received as evidence that a syphilitic taint 
in the father or the mother can, exclusive of other causes, pro- 



TERTIARY SYPHILIS. 403 

duce scrofula in the child. . . . From all these circum- 
stances I arrive at the conclusion that scrofula and syphilis 
are independent one of the other ; that each has a character 
proper to itself, and that the same treatment is inapplicable to 
both diseases. For example, if scrofula be rife where syphilis 
is rare ; if syphilis affects all periods of life, while scrofula is 
more confined to a particular period ; if hereditary syphilis be 
manifested at or soon after birth, while scrofula unfrequently 
appears before the second or third year ; if syphilis, whether 
inherited or acquired, be rarely cured spontaneously, and if, 
as every one knows is the case, scrofula often disappears at the 
approach of puberty ; if syphilis usually yields to mercurial 
treatment, while scrofula does not, — should we not conclude 
that the one has no dependence on the other ? " 

Among the most remarkable and interesting phenomena 
developed within or beneath the cutaneous membrane are the 

Tubercula Gummata. — These, tumors usually appear at a 
very late period in the train of consecutive symptoms orig- 
inating in a chancrous sore, and by common consent they 
occupy a position in the tertiary group of venereal affections. 
Occasionally they are formed in the substance of the skin, but 
for the most part they lie below the true corium, and have the 
subcutaneous cellular tissue for their nidus. Here they may 
remain for an indefinite period in an indolent state, without 
infringing upon the healthy condition of the adjacent parts. 
In rare instances they have been known to show themselves 
within a few months from the primary disease, but ordinarily 
they do not form until the lapse of several years after the 
introduction of the syphilitic ferment into the system ; and 
comparatively but few individuals who have had chancres are 
ever afflicted with this variety of tubercles. 

These curious abnormal bodies are hard and slightly elastic 
to the touch, and, when lodged where the cellular tissue is 
quite deep and abundant, they are movable in almost any 
direction ; if gently felt with the thumb and finger, they seem 
to float, as it were, or to be suspended in the cellular sub- 
stance in a loose manner. They sometimes attain the size of 
a hen's egg. They are called by different names, as gummata, 
tubercles in the cellular tissue, tubercula gummata, tumores 



404 GONORRHOEA AND SYPHILIS. 

gummati, tumeurs gommeuses. In process of time, perhaps, 
many months or years, an inflammatory action may be excited ; 
they lose their mobility, and form adhesions to the skin, which 
by slow degrees becomes disorganized, and an ulcer of peculiar 
character is the result. The morbid process eats its way 
through the integument at different points, and complete per- 
forations are made through it and extend to the interior of the 
tumor, which is sooner or later converted into a decomposed, 
sloughy pulp. The bridles of skin between these artificial 
apertures undergo a gradual absorption, and a large, open, 
deep ulcer is ultimately established. Sometimes several of 
these tumors are seen side by side, and suppurate successively ; 
and the ulcers which follow are extremely difficult to heal. 
They are usually associated with other venereal accidents, and 
their occurrence denotes that the economy is profoundly 
affected by the syphilitic cachexia. Generally not more than 
three or four specimens are present at any one time, unless 
they appear in groups, which, is rarely the case. They occupy 
localities remote from each other ; for instance, one will be 
found upon the neck, one or two on the fore-arm, and one in 
the popliteal space, and perhaps one or more within the 
mouth, subjacent to the mucous membrane. If they happen 
to be dispersed, — as they often are when attended to seasonably, 
— another crop will very likely arise in their stead in the course 
of a few months, and thus a succession may be continued for 
several years. 

Diagnosis. — It is seldom a difficult matter to distinguish 
these singular formations from all other morbid developments. 
If they are unaccompanied by other specific manifestations, a 
truthful history of the patient will bring to light all that the 
surgeon needs to know. But if the antecedents are studiously 
concealed, and a solitary subcutaneous tumor should advance 
to suppuration and slow phagedenic ulceration, the case might 
be mistaken for a scrofulous or cancerous affection. 

Cases of Tubercula Gummata. — June, 1858. -—For about 
three years I have had under my care a young Scotchman, who 
had primary syphilis ten years ago. Secondary symptoms came 
on four years afterwards. 



TERTIARY SYPHILIS. 405 

The patient has at times had sore throat, with pretty extensive 
ulcerations ; the tonsils are destroyed, and cutaneous affections 
have existed in almost every variety of type and severity. Dur- 
ing the past year the skin has remained sound, and the mouth 
and throat are now nearly so. For two or three years past, 
periosteal pains have prevailed at times, but have not been of an 
obstinate character. Ten months since, a subcutaneous, elastic, 
movable tumor was developed close under the base of the left 
nipple, and soon afterwards a similar product came on the right 
side of the neck, one inch below the mastoid process. The 
nodule on the breast increased more rapidly than the other, 
until it became as large as a common walnut. The one on the 
neck was smaller. Both were somewhat painful and more 
elastic as they enlarged, and in all respects corresponded 
with the descriptions given of syphilitic tubercles in the 
cellular tissue, and which, when they suppurate, give rise to the 
horse-shoe or serpiginous ulcer, having a phagedcenic tendency. 

The iodide of potassium is the principal remedy which this 
patient has taken during the last six months. The daily 
amount has ranged from fifteen to thirty grains, having been 
wholly omitted on several occasions" for five or six days. The 
tumors have disappeared. 

Case II. — In October, 1854, a young married woman, whom 
four years previously I had attended for severe secondary affec- 
tions, presented herself, having two gummy tubercles, one on 
each side, just below the angle of the jaw. They were not en- 
larged lymphatic glands. They had existed for four months. 
The one on the right side was of the size of a marble, the other 
a little less. They caused but slight inconvenience, although 
occasionally they were somewhat tender and painful. They 
seemed to be loosely suspended in the cellular membrane, and 
would slip from between the thumb and finger, unless secured 
by a careful grasp. 

In this case the iodide of potassium was prescribed to the 
amount of a scruple per diem, and in less than three weeks 
both tumors vanished: A few months afterwards similar 
growths sprung up in the same neighborhood, and the potassium 
was again resorted to with like beneficial results. Coetaneously 
with these gummata, the patient had caries and exfoliation of 



406 GONORRHOEA AND SYPHILIS. 

the nasal bones ; and in consequence of this ostitis, the lachry- 
mal apparatus became involved. The sac inflamed, a tumor 
formed at the inner canthus of the left eye, and suppuration 
ensued. The abscess was punctured at several different times 
for the purpose of liberating the purulent collection. It finally 
became necessary to introduce a canula into the lachrymal 
canal, where it was allowed to remain for a few weeks. I am 
aware that the use of the canula, under such circumstances, is 
regarded by some ophthalmic surgeons as a measure of doubtful 
propriety, as it is supposed in some cases to favor the process 
of necrosis. The loss of bony substance in this instance took 
place chiefly before the insertion of the stilette. This destruc- 
tion of bone was sufficient to cause a depression and consequent 
deformity of the organ ; there were also obstructed respiration 
and impaired phonation. The patient was under my care and 
that of other medical men for about five years. She took mer- 
cury at various times, but never to a point beyond producing a 
slightly disagreeable taste. She was naturally of a scrofulous 
diathesis, had a frail constitution, and was too feeble to warrant 
the free employment of any mercurial preparations, which were 
always administered as supplementary or subsidiary to tonics, 
iodide of potassium, chalybeates, and diaphoretics. Dr. Egan, 
who is generally good authority, expresses his assurance that 
caries of the nasal bones never results solely from the absorption 
of the syphilitic poison, but is occasioned by the injudicious and 
repeated use of mercury. In the case here related, however, I 
do not hesitate to attribute the nasal lesions to the agency of the 
venereal disease alone. 

Case III. — I am reminded of another instance of the for- 
mation of subcutaneous tumors in a sea-captain, who had su£ 
fered severely from the ravages of constitutional syphilis for 
several years. He had, originally, an iron frame, which bravely 
resisted the encroachments of the malady for a long period be- 
fore tertiary lesions manifested themselves. But these finally 
came on, and caused dreadful mutilation and destruction within 
the mouth and nose, and upon the face. A gummy tubercle 
formed in the cellular substance of the left cheek, and in a few 
months became so large as to interfere with the mastication of 
the food, and wi th other functions requiring motion of the part?- 



TERTIARY SYPHILIS. 407 

This tumor was carefully removed by a surgeon, and no ill con- 
sequences supervened. A similar mass showed itself in front of 
the tragus of the right ear. It ulcerated while the patient was 
far at sea, remained open for many months, and finally healed 
without spreading much in any direction. It never yielded a 
large discharge of any kind. Isolated deposits of the same 
description were developed near the angles of the lower jaw, 
and in other situations about the neck, and on the arms. The 
iodide of potassium was efficacious in accomplishing their 
absorption. 

Syphilitic gummata are occasionally met with in the muscles. 
Ricord states that as soon as this venereal condition commences, 
the muscular tissue, which seems to undergo a sort of degener- 
ation, contracts, but this contraction is hardly noticeable as 
long as the muscle gets passively shorter. There is at first a 
plastic transformation, which may by proper treatment entirely 
disappear without any deformity being left behind ; but, if the 
disease be allowed to reach a more advanced stage, the conse- 
quence may be either a complete atrophy, through resorption, or 
a fibro-cartilaginous or osseous formation. In the latter case 
there is shortening of the affected muscle. This degeneration 
usually attacks the flexor muscles, as for instance the biceps, 
the gastrocnemii, etc. Ricord relates the case of a celebrated 
singer who consulted him for such a syphilitic contraction of the 
biceps, which interfered with the proper action of the arms on 
the stage. He was put on the iodide of potassium, and pro- 
gressed very nicely, — so much so that resolution gradually en- 
sued, and, while the public were applauding his splendid vocal 
powers, Ricord used to join them enthusiastically, enraptured as 
he was with the vigorous action of the arms and the triumph of 
the iodide. 

In connection with the formation of gummy tumors in the 
muscles, another syphilitic affection, termed Myositis, has been 
observed in a few cases. This transformation is consequent 
on a subacute inflammation of the muscular tissue. It com- 
mences gradually with moderate pain, especially at night, and 
some constraint in the normal movements of the limb. The 
muscles enlarge slowly, become harder, more elastic, and their 
contraction is difficult, painful and imperfect. In the prog- 
ress of the disease the hardness of the muscles increases, and 



408 GONORRHOEA AND SYPHILIS. 

approaches that of cartilage, and movement is impossible*. ThL 
condition is followed by an atrophic shortening. 

Acton states that he has witnessed several cases of these 
tumors in the muscles, particularly in the biceps. He relates 
the history of one which he saw in Paris. It was as follows : 

" Eight years ago a man contracted chancre, which did not 
become indurated. Two years later — that is, six years since — he 
had a second infection ; induration came on ; he remained free 
from disease until two months ago, when a tubercle formed in 
the masseter, and another in the substance of the gastrocnemius. 
The limb became enormously enlarged, but had entirely subsided 
under the use of the iodide of potassium, with plasters of am- 
moniacum and mercury." 

At the autopsy of a venereal subject, Bicord found in the 
walls of the ventricles of the heart several points of tuber- 
culiform alteration, consisting of a yellow substance of scirrhous 
hardness at some points, at others analogous to that of tuber- 
cular matter in process of softening. These deposits he regarded 
as possessing the characters of tertiary syphilitic nodes or tu- 
bercles, which are observed in the subcutaneous or submucous 
cellular tissue. In the case here cited the cardiac muscular 
fibres were involved. 

These circumscribed syphilitic gummata or nodes are fre- 
quently developed among the tendons of the muscles. They 
spring either from the surface of the tendon or from its interior. 
They present different characters at different times, according 
to the various transformations which they are known to undergo. 
Accordingly, when examined, they are found to be fibrous, 
elastic, semi-fluid, fluctuating, or perfectly solid. Sometimes 
inflammation is set up, and they terminate in a sort of furuncu- 
lar suppuration ; at other times ossification occurs. In some 
instances, extensive portions, or even the entire length of 
a tendon, may be involved in the affection. 

In some cases, even where these tubercula acquire a very 
large size, they are productive of very little pain, and about the 
only inconvenience which the patient experiences from their 
presence arises from an impediment in performing the several 
motions of the limbs. In other cases they interfere with the 
normal action of the nervous centres or ganglia, or some portion 
of the cerebro-spinal system, causing great irritation, pain, and 



TERTIARY SYPHILIS. 409 

partial paralysis. They have been found in the epididymis, 
testicle, liver, lungs, brain, bones, etc.* 

In fact, no organ or tissue in the human body can escape the 
venereal infection. Even the nerves, the teeth, the hair, and the 
nails are involved. In the syphilitic subject there is a tendency 
to the exudation of a low form of lymph or fibro-plastic material 
modified in character by the organ in which it occurs. On the 
skin and in the mucous membranes its disposition is to soften 
and finally result in ulceration. On the bones it may proceed 
to ossification, or produce caries. On the tongue and other 
muscles it develops itself into hard lumps or tumors when it is 
not modified in its natural progress by the action of medicines. 
In the earlier period these nodules appear to infiltrate the part 
they occupy, and are comparatively soft ; but after they have 
existed for a considerable time they become harder, more dis- 
tinct and separate from the neighboring tissues ; and at a still 
later stage they often ulcerate. These changes are frequently 
seen in the syphilitic tubercles or tumors that appear on the 
tongue.f 

TREATMENT OF TUBERCULA GUMMATA. 

Experience has at last demonstrated to the satisfaction of 
every practitioner who has much to do with the management 

* " A special kind of exudation is seen in what is termed gummata. 
Lobstein describes it under the name of " gumma periostitis," and compares 
the contents of these nodular swellings, as respects their consistence, with a 
semi-fluid mucilage of gum arabic, and of the color of currant jelly. The seat 
of these gummata he places in the tissue of the periosteum itself, or, more 
often, between that membrane and the bone." — WedVs Pathological His- 
tology, p. 235. 

Mr. Busk, in a note, remarks : " In syphilitic gummata, such, for instance, 
as are frequently observed on the frontal and breast bones, the contents are a 
glairy fluid, containing but few morphological elements. The latter consist 
chiefly of irregular molecules and colorless granule cells, and granular masses, 
often consisting apparently of oil spherules, surrounding a transparent mass ; 
but, notwithstanding the apparently complete separation of the periosteum 
from the bone by this heterogeneous product, it rarely happens, if the case be 
properly treated, and the opening of the tumor be avoided, that any exfoliation 
takes place." 

t In Guy's Hospital Reports for 1863, Mr. Wilks has communicated some 
interesting remarks on this subject. 

35 



410 GONORRHOEA AND SYPHILIS. 

of syphilitic patients, that the specific powers of mercury to 
control venereal affections become more and more feeble in 
proportion as these phenomena recede from the original in- 
fection ; and we have seen that the lesions now under noti:e 
are among the most tardy constitutional affections entailed 
upon the system. 

While I wish to be included among the advocates for the 
cautious administration of mercury in primary syphilis, and 
in many secondary lesions, I should be chargeable with being 
under the dominion of a blind and illiberal prejudice, and 
of heing behind the improvements of the day, did I not 
admit the superiority of the iodide of potassium over all other 
medicines in the treatment of tertiary phenomena. This con- 
viction has not been brought about solely by the statements of 
others, but is also the result of my own observation of its ex- 
traordinary sanative power. These tertiary evils, in their 
severer forms, at least, would probably appear less frequently, 
if their predecessors in the chain of abnormal actions were 
resisted by suitable ferro-mercurial treatment, combined with 
the observance of proper hygienic principles. But such a 
remedial course is not, and cannot, always be pursued. The 
medical man must therefore be prepared to encounter the class 
of symptoms now before us with all the skill he is master of. 

Iodide of Potassium. — In a recent paragraph I have partly 
anticipated what I must here repeat, that, in the treatment of 
the tubercula gummata, our chief reliance must be upon the 
iodide of potassium, so far as our dependence can be placed on 
medicinal agents ; and yet there may be occasion to employ 
others at the same time, or even before the potassium is pre- 
scribed. The physician should at any rate diligently inquire 
whether any local inflammation or irritation exists in any 
organ, and which demands, perhaps, a brief employment of 
some gentle antiphlogistic or anodyne. The condition of the 
stomach and bowels, or of the biliary apparatus, may require to 
be rectified ; or the use of tonics and a pretty full diet may be 
requisite to elevate the depressed state of the system, before the 
potassium can be resorted to with the best advantage. If the 
patient have a capricious appetite and impaired digestion, — if he 
be troubled with constipation, with restless nights, or with any 



TERTIARY SYPHILIS. 411 

abnormal sensations of a serious character, and referable to any 
of the vital organs or functions, — it will be important to relieve 
him of these annoyances before attempting the removal of any 
specific venereal symptoms. But as soon as the constitution 
has been suitably prepared for the reception of the salt in ques- 
tion, its beneficial influence will be realized in all cases of gum- 
mata that are amenable to any therapeutic agent. We have 
the experience and testimony of the most distinguished men 
now active in the medical and surgical ranks, all over the civil- 
ized world, to justify us in the belief that this remedial sub- 
stance is entitled to hold the same position in the management 
of these and other tertiary symptoms that has been accorded to 
mercury in primary and secondary affections ; and this is say- 
ing all that need be offered in praise of any ingredient in the 
materia medica. 

Not a few medical practitioners have expressed disappoint- 
ment at the results which have followed the use of the potas- 
sium as prescribed by them for venereal affections that appear 
at a late period. I am of opinion that the article has been 
employed somewhat indiscriminately for secondary and tertiary 
lesions, and hence the frequent failures. In presuming to sub- 
mit this remark, I am willing to include myself among those 
who have erred in thus prescribing it. The high encomiums 
which, a few years since, came over from European hospitals to 
this country, respecting the healing virtues of the potassium in 
certain syphilitic symptoms of long standing, naturally excited 
the hopes of medical men in advance of any practical experi- 
ence they had acquired of its merits ; and in this country, at 
least, its popularity preceded its employment, and the hasty 
and hap-hazard administration of the salt has in many instances 
brought disappointment Even in tertiary syphilis I have 
known patients to be put upon its use under circumstances 
unfavorable for the realization of any beneficial results. 1 
could cite instances where the parties have been so situated 
that no advantage could be derived from salubrious air, bath- 
ing, generous diet, and other hygienic measures, the influence 
of which it is always so desirable and important to weave in as 
auxiliary in the treatment of all venereal symptoms. In such 
cases the medical attendant, as well as the patient, is truly 
unfortunate ; but no maledictions should fall upon the remedy 



412 GONORRHOEA AND SYPHILIS. 

tinder consideration, although it fail to do good when adminis- 
tered under such adverse circumstances. It has a Herculean 
task to perform to subdue the' monster that has so long held 
possession of the ground ; but it cannot work miracles. 

In syphilitic gummata, as well as in all other tertiary acci- 
dents, the daily quantity of the salt may be from fifteen to 
twenty grains for the first three or four days, after winch it will 
be safe to increase the dose, if the patient experience no un- 
pleasant effects. It has been frequently prescribed to the 
amount of one and two drachms per diem, according to its 
therapeutic energy and the peculiar condition of the person 
taking it. A favorable change usually takes place in the 
symptoms in a short period, and as soon as this improvement 
declares itself it will be judicious practice to keep the amount 
given at the point which appeared to cause the amendment. 
It is better for the physician to allow himself this latitude as to 
the quantity he recommends, rather than be governed by any 
mere mathematical rule. A diminution in the size of the 
tubercles is in some instances perceptible within forty-eight 
hours from the time the individual begins to take the salt ; and 
I have known specimens of the bigness of a common marble 
to be obliterated within ten days through its agency. It is not 
very unusual to find old tertiary ulcerations and long-standing 
nocturnal pains of syphilitic origin in the bones coincident with 
the gummata. Such cases afford the most gratifying proof of 
the excellent powers of the iodide ; for while the gummata sub- 
side under its action, the ulcers rapidly amend or heal, and the 
osseous affection ceases to torment. Instances have been au- 
thentically reported in which syphilitic tumors as large as an 
orange, and situated among the muscles, have been carried 
away by absorption in the course of six weeks, the potassium 
being the chief constitutional means resorted to. If the situa- 
tion of the tumors will allow of the employment of pressure, 
mercurial plasters may be applied as useful auxiliaries. The 
iodide of lead ointment, one drachm to the ounce, has the repu- 
tation of acting beneficially as a discutient. So has the tincture 
of iodine. 

While the patient is taking the potassium, he should be 
allowed a good, regenerating diet ; and for drinks, wine, por- 
ter, and ale in generous quantities. 

The above course may be continued for weeks or months 



TERTIARY SYPHILIS. 413 

without danger of inducing any unfavorable consequences. 
Even after the particular morbid symptoms, for which the 
potassium was given, have disappeared, it will be judicious to 
continue its use in small doses for several weeks, for the purpose 
of preventing relapses, as well as with a view of recruiting the 
condition of the system. 

When the subcutaneous gummata yield a slight fluctuation 
on pressure, and the integument is not discolored, it will be 
proper to attack them with energetic local means. The skin 
may be covered with a blister, and as soon as the cuticle is 
detached the raw surface may be dressed with strong mercurial, 
ointment for the purpose of encouraging absorption of the pur- 
ulent collection. If fluctuation should increase, the contents 
of the tumor should be set free with the lancet, as all further 
attempts to induce absorption will not only prove abortive, but 
the pus, if not evacuated, will undermine the integument in 
every direction, and great -ravages among the different tissues 
will be likely to occur. If the tumor be situated on the scro- 
tum, it will be especially important to open it at the earliest 
moment after the softening and fluctuation are detected. The 
suppurating surface will require a subsequent local treatment 
of a somewhat stimulating character. The chloride of soda 
makes one of the most useful topical dressings for these un- 
healthy sores. The black wash, the yellow wash, the Peruvian 
balsam, and a solution of the potassio-tartrate of iron will all 
likewise act favorably. 

If there be much redness and inflammation in the surround- 
ing parts, a soothing application will be demanded in preference 
to one of a stimulating nature. A saturated solution of the 
extract of opium should be applied to the ulcerated surface for 
a short period, and afterwards one of the preceding remedies. 
In most cases the abnormal local action is of a subacute type, 
and the ulcerations, that are almost certain to supervene upon 
the opening of the gummata, present a sloughing tendency, to 
arrest wiiich, stimulants applied directly to them will be most 
appropriate. In addition to those above named for daily use, 
the nitric oxide of mercury ointment will be found an excellent 
preparation for nocturnal use. The occasional employment of 
the undiluted nitric acid will be requisite if the ulceration 
extend into the soft parts. 
35* 



414 GONORRHCEA AND SYPHILIS. 

In such cases the malady is wont to assume a formidable 
aspect, and it is not only necessary to resort to topical meas- 
ures with the intention of destroying the phagedenic action ; 
but our main reliance must be on constitutional treatment, 
which, in addition to the iodide of potassium, should consist of 
the free administration of the potassio-tartrate of iron, quinine, 
opium, wine, etc. 

In the treatment of primary sores, the potassium is of no value. 
The same is true as regards the early stage of secondary 
eruptions. Cases are recorded in which this salt has been taken 
for many months for the cure of pustular and tubercular affec- 
tions of the skin without any permanent advantage. Some- 
times it will suspend or keep under such eruptions for a while, 
but, as soon as it is omitted, these phenomena will return as 
severely as ever ; and, from the numerous trials that have 
been made with it, it appears to be a well-established fact that 
its therapeutic qualities are in direct ratio with the long con- 
tinuance of the specific symptoms. Experience has now sup- 
plied ample proof that, under its action, tertiary or very late sec- 
ondary ulcerations of the soft tissues heal rapidly, that pains 
in the bones are relieved or annihilated, that exostoses are to- 
tally destroyed, that extensive periostoses are arrested in their 
progress, that old sequestra are promptly eliminated in very 
many instances, and that tedious and distressing caries will dry 
up and cicatrize in a permanent and healthy manner. 

What may be termed the more extraordinary degrees of 
tertiary accidents, such as are mentioned in the preceding par- 
agraph, are seldom met with in private practice. Although 
I am constantly dealing with this class of accidents in all 
their forms, my experience is quite limited in regard to in- 
stances of peculiar severity. Painful swellings and plastic 
infiltrations about the joints, and periosteal and osteal inflam- 
mations accompanied with nodes, are the most frequent ter- 
tiary lesions I am called upon to treat. For the removal of 
these, my reliance is on the iodide of potassium as the great 
constitutional antidote. I have often witnessed with sur- 
prise the rapidity of its therapeutic action. Within three 
days from the commencement of its use to the amount of 
thirty or forty grains, per diem, I have known articular en- 
largements of several months' duration begin to decline, and 



TERTIARY SYPHILIS. 415 

to be entirely reduced in a few weeks. In one instance lately 
under my care, and in which Dr. S. D. Towsend was called 
in consultation, the enlargement of the knee-joint was over 
two inches, and in three weeks it almost wholly disappeared 
under the influence of the iodide, which was prescribed at the 
rate of one drachm daily. Equally favorable results are 
realized when it is employed for subduing other local affec- 
tions appertaining to the tertiary group ; and as the remedy 
displays its power over these, the general condition of the 
system undergoes great improvement also. The tongue be- 
comes clean, the appetite returns, the digestion is good, and 
the patient is very sure to increase in flesh. The data upon 
which these statements are predicated are derived from my own 
observation of the potassium in numerous cases of tertiary 
syphilis, in which the effects of this medicine have almost uni- 
formly been such as to remind me of the expression of Ricord, 
that it is "all-powerful." And when I hear of failures and dis- 
appointments connected with its administration, I always sus- 
pect that it has been prescribed in cases not belonging to the 
tertiary, nor yet the late secondary period, or that it has been 
given in a manner or under circumstances that would render 
any medicinal agent nugatory. 



CHAPTEE XXXVII. 
SYPHILITIC SARCOCELE, OR ORCHITIS. 

This is a chronic affection. Some writers consider it a sec- 
ondary venereal malady ; others class it among the tertiary 
symptoms. I have met with it in persons who have had 
secondary papular and pustular eruptions at the same time, 
but no tertiary complaint ; and I have seen it where the other 
concomitant affections were strictly tertiary. In one instance a 
man was troubled with sarcocele during secondary consecutive 
manifestations, and also after tertiary lesions had existed for a 
long time. Thus, abstractly considered, this glandular diffi- 
culty belongs to no one period of syphilis exclusively. Nor is 
it strictly accurate to regard it as occupying a transition state 
between the secondary and tertiary epochs. 

The disease has been known to appear at the same time with 
primary chancre, and in connection with the profound abnor- 
mal phenomena that attack the periocteum and bones ; and it 
may occur at any moment intermediate between the extremes 
here mentioned. This irregularity as to the times of its devel- 
opment has created doubts in the minds of some surgeons as 
to the propriety of separating venereal manifestations into three 
distinct divisions. 

As a general rule, it may be stated that orchitis is one of the 
latest exhibitions of the syphilitic disease. It commences in 
the tunica albuginea, or the fibro-cellular tissue of the body of 
the testicle, and not in the tubular portions of the organ. In 
its incipient stage the epididymis is not involved. The numer- 
ous researches of Sir Astley Cooper have placed these facts 
beyond doubt. In a majority of cases both testicles are in- 
volved in the morbid action simultaneously ; in others only one 
testis is implicated. The enlargement proceeds very gradually, 
is attended with only a moderate degree of pain, and the indi- 
vidual will allow the part to be handled without complaining. 

(416) 



SYPHILITIC SARCOCELE, OR ORCHITIS. 417 

For some time the gland preserves its smoothness and its 
natural pyriform or ovoidal figure ; but as the disease ad- 
vances it becomes globular, and assumes a fleshy feel, from 
which circumstance is derived the term sarcocele* After a 
considerable period has elapsed the smoothness of the surface 
is slightly interfered with by prominences occasioned by the 
presence of tubercles, or zones, as they are sometimes called. 
These, however, eventually coalesce into one mass. In certain 
instances, where there is great hardness of the gland, it pre- 
sents a somewhat irregular, lobulated appearance. As the dis- 
order becomes still more chronic, the epididymis participates in 
the inflammation, and is merged in the general enlargement, so 
that it cannot be felt. In the generality of cases the trouble 
terminates in resolution, and the testicle is restored to its 
natural size. Now and then a slow process of foul, unhealthy 
suppuration is set up.f In such cases the patient suffers in- 
tense pain ; but otherwise there is merely a dull, aching sensa- 
tion, accompanied by a feeling of weight in the organ, as in 
non-specific orchitis. 

Instances are occasionally reported of the disease terminating 
in atrophy of the gland. This condition has been erroneously 
attributed to the physiological influence of the iodide of potas- 
sium. The wasting away of the testicle may sometimes be the 
result of the specific affection, or it may arise from neglect, or 
from improper management, or it may be due still more fre- 
quently to some peculiar diathesis inherent in the constitution. 

There is one feature appertaining to this variety of sarcocele 
which it possesses in common with nearly all the other consti- 
tutional venereal affections, and that is a disposition to recur. 
Even if the treatment have been entirely successful in removing 
the engorgement, the probability is that after an interval of a 
few months the same difficulty will return, although perhaps in 
a mitigated form. 

* From aaqt, flesh, and xijlq, a tumor. 

+ Mr. Acton is of opinion that syphilitic sarcocele never brings on suppura- 
tion ; and the late Mr. Colles remarks that he could not recollect any case of 
what he considered purely venereal swelled testicle which went on to sup- 
puration, although he had seen this occurrence take place in some persons 
where the debilitated and deranged state of the health appeared to be the 
exciting cause. 



418 GONORRHCEA AND SYPHILIS. 

In former times the complaint under consideration, not so 
well understood as at the present day, was often looked upon as 
cancerous ; and surgeons who were fond of using the knife 
were frequently too ready to relieve the patient of his testicle 
by castration. 

In ordinary cases of orchitis, virility remains unimpaired ; 
but if both testicles are diseased, and the morbid condition con- 
tinue for a very long time, producing disorganization in the 
seminal tubes, then their normal function may be destroyed ; a 
circumstance, however, which rarely happens. 

Diagnosis. — The testicular engorgement generally takes 
place amid circumstances calculated to shield the judgment of 
the practitioner from any mistake as to the precise nature of the 
swelling. Other constitutional symptoms of a specific type will 
be present. Upon an examination of the patient, if such a 
ceremony should be necessary, tubercles, cutaneous, subcuta- 
neous, or submucous, chronic and unhealthy ulcerations, phage- 
denic sore throat, nodes, iritis, scaly eruptions, or articular 
pains, will probably be found to exist. But if these venereal 
symptoms should all happen to be absent, the history of the 
individual for the few previous years will develop facts, a 
careful analysis of which will point with sufficient distinctness 
and emphasis in the right direction ; so that the diagnosis will 
be rendered easy. 

Pathological Appearances. — On dissection, the general 
appearance furnished by the syphilitic testicle exactly corre- 
sponds with that of the common chronic inflammation of this 
body. The glandular structure of the organ exhibits a quan- 
tity of yellow, unorganized matter, collected in small masses or 
deposits, possessing more or less solidity.* 

TREATMENT OF SARCOCELE. 

Local. — If the case be presented for treatment at an early 
period, and before any material structural change has taken 
place in the part, it can usually be restored to a healthy condi- 
tion without difficulty. Should it be very painful and tender, 

* Cooper, Brodie, Hamilton, Curling. 



SYPHILITIC SARCOCELE, OR ORCHITIS. 419 

five or six leeches must be applied to the scrotum, which should 
be supported by a suspensory bandage. The frequent use of 
hot vapor or of soft warm poultices will exert a soothing influ- 
ence, and likewise materially assist in reducing the enlargement 
of the gland. The fomentations or poultices should contain a 
solution of the extract of belladonna, which will add to their 
efficacy. The iodide of lead ointment will sometimes prove 
beneficial in promoting the absorption of the plastic infiltration. 
It will be a good practice, also, to paint the scrotum with the 
compound tincture of iodine every day, so as to maintain a 
lively counter-irritation. Blisters are serviceable where the 
sarcocele has become chronic. Many surgeons have great faith 
in the resolvent qualities of mercurial ointment. I have no 
objections to otter to its employment, nor do I entertain any 
special confidence in it as being superior to the other local 
appliances that have been mentioned. Its use is attended with 
no little trouble, on the score of uncleanliness, which over- 
balances any specific advantages that can be urged in favor of 
it, while we have at command an abundance of other resources 
of equal curative value. 

If there be a high tone of inflammatory action, refrigerating 
lotions will be demanded for the time being ; and the patient 
will likewise derive advantage from a general warm-water bath 
morning and evening. 

Constitutional Treatment. — The iodide of potassium will 
prove the most beneficial medicine that can be addressed to the 
constitution. This salt will be especially appropriate if the 
orchitis be developed in patients in whom tertiary phenomena 
are more predominant than secondary. 

In regard to the necessity or desirableness of prescribing 
mercury in any form or quantity, I am inclined to the belief 
that the general condition of things will seldom warrant such a 
procedure, except in the most cautious manner. Nine-tenths of 
the persons who present themselves to the medical man for the 
treatment of swelled testicles, are just the ones who cannot be 
put upon a mercurial course without incurring a risk which the 
exigencies of the case do not justify. It is far safer and better 
to rely upon the action of the potassium and the other remedial 
measures recommended in connection with this subject. 



420 GONORRHOEA AND SYPHILIS. 

If there be considerable effusion into the tunica vaginalis, it 
will be advisable to puncture it with a small trocar. This 
operation will greatly promote the success of the subsequent 
treatment. 

SYPHILITIC EPIDIDYMIS. 

Syphilitic disease of this part may exist independently of any 
organic lesion of the testis itself. M. Dron has furnished 
accounts of quite a number of oases he has met with at the 
Venereal Hospital at Lyons. Of the cases reported by him two 
had syphilitic orchitis at the same time. 

When the head of the epididymis is not exclusively the seat 
of the syphilitic tumor, it is always the part in which it be- 
comes most developed, and persists the longest. Generally the 
tumor does not exceed a nut or an olive in size, the largest 
being equal to a small walnut. Its surface is irregular and 
knobby, and its solidity increases with its duration. It is always 
easily distinguished from the testicle, and it is usually very 
indolent, so that the patient himself may not be aware of its 
existence. Sometimes, however, the disease is attended with 
more or less pain. The functions of the organ do not appear 
to be influenced by the presence of the tumor, which is also 
generally unaccompanied by lesions of any other portions of the 
spermatic apparatus. The period of its first appearance cannot 
always be determined, so little has it excited the attention of the 
patient. In some cases the swelling or tumor is noticed within 
three or four months after the existence of a chancre, while in 
other instances it has been much later. Left to itself its dura- 
tion seems to be almost indefinite, as it is met with many 
years after the occurrence of the primary disease. The tumor 
for the most part readily yields to treatment, and a cure is ac- 
complished in two or three months. A few cases of pure 
syphilitic epididymitis, independent of any coexisting lesion of 
the testis, have come within my observation. They have not 
been of a grave character, and have terminated by resolution. 
The complaint occasionally shows a disposition to return. 

The iodide of potassium constitutes the most efficient, and in 
fact about the only remedy required. Local applications are of 
no account. 



CHAPTER XXXVIII. 

DISEASES OF THE PERIOSTEUM AND BONES. 

Syphilitic diseases of the bones and of their investing mem- 
brane, the periosteum, are less frequently met with at the 
present day than formerly. One, and perhaps it might be said 
the chief 7 reason of this difference is to be found in the mild 
treatment which the members of our profession have of late 
years chosen to employ for the cure of secondary symptoms. 
To the exhausting effects of the immense quantities of mercury, 
which it was once the custom to crowd into the stomach 
while the system was struggling against the malign influence of 
the venereal poison, is doubtless to be attributed a large share 
of those violent and destructive morbid processes which preyed 
upon the bones of its subjects. 

Syphilitic accidents appear most frequently in those bones 
that are thinly covered with muscles, and consequently exposed 
to varieties of temperature. Of all the bones, the tibia suffers 
most from tertiary affections. The cranium, the clavicle, the 
radius, the ulna, the inferior maxilla, the sternum, and ribs, are 
also obnoxious to specific pains, inflammation, nodes, tumors, 
necroses, and caries. It is scarcely probable, indeed, that any 
portion of the osseous system enjoys immunity from the effects 
of the disease. 

Osteocopic symptoms are ushered in without any apparent 
exciting cause. A dull, circumscribed pain is seated, for in- 
stance, at a fixed point upon the shaft of the tibia. It does 
not shift from place to place, as an ordinary rheumatism ; is 
not accompanied by redness, swelling, or increased tempera- 
ture ; is intermittent, and for a long period is almost wholly 
nocturnal. If, however, no attempt be made to annihilate it, 
the individual ultimately suffers by day as well as by night. 
Sometimes, when pressure is made upon the part, the distress 
is increased, — thus proving that the affection is deep-seated. 
36 C 421 ) 



422 GONORRHOEA AND SYPHILIS. 

In the latter class of cases the syphilitic inflammation may- 
attack either . the medullary membranes or the cancellated 
structure of the long bones. Where the disease is deep-seated 
in the bones of the extremities, a morbid deposit takes place, 
accompanied with intense suffering, in consequence of the 
unyielding nature of the surrounding tissues ; and the opera- 
tion of trephining can alone give relief. Surgical experience 
has demonstrated this fact. 

Syphilitic osteocopes are regarded by some eminent authori- 
ties as only a symptom of an affection of the bones, and not as 
a distinct malady. In reply to this, it may be stated that per- 
sons are occasionally met with who suffer tertiary pains for 
many months before any organic lesion is manifested, although 
in most cases these osteocopes do not continue but a few weeks 
before some serious derangement takes place, either in the peri- 
osteum or bone. Generally a slight tenderness on pressure is 
perceptible at the spot where the disease is located, and, in a 
short time, irregularities and periosteal enlargements, termed 
nodes, reveal themselves. These abnormal deposits are more 
frequently developed in persons who have been subjected to the 
protracted use of mercury than in those who have not been 
thus treated. They are seen, however, as purely venereal acci- 
dents where no mercurial preparations have been administered. 
They do not exhibit precise uniformity in their appearance or 
character, and have been separated by Ricord into three differ- 
ent varieties, viz., the elastic, the phlegmonous, and the plastic. 
Several nodes are frequently noticed on the same bone at the* 
same time. When they thus appear they are generally of 
smaller size than when a solitary specimen exists. Their out- 
lines are not always well defined. The central part is usually 
more prominent than the other portions of the swelling, and, as 
the finger follows the morbid growth from the summit towards 
the basal periphery, it is often difficult to trace it distinctly. 
Sometimes the nodes form without being preceded by a painful 
condition in the place from which they spring ; but in most in- 
stances, as already stated, they are ushered in by pretty severe 
and constant pain. Nodes may remain indolent for a long 
period, may undergo little or no alteration, and occasion 
but very little inconvenience ; on the contrary, they sometimes 
prove extremely troublesome, and are premonitory of still more 



DISEASES OF THE PERIOSTEUM AND BONES. 423 

serious and profound lesions that are sooner or later to follow. 
In some instances the lymph, or serum, which they contain can 
be carried away by absorption ; in others a slow process of sup- 
puration is excited, abscesses form between the periosteum and 
the bone, and exfoliation of the latter, to a greater or less 
extentj ensues. This is particularly liable to be the case where 
the periostitis is situated upon some portion of the cranium. 
Instead of remaining soft, doughy, and painful, as in their 
incipient stage, they sometimes change their character after 
they have existed a few weeks. They acquire solidity, and 
cease to be painful. This solidity or hardness does not of 
itself indicate the composition of the nodular deposits. Mr. 
Stanley states that he has found what was supposed to be osse- 
ous matter to prove mere indurated periosteum. The peri- 
cranium differs from the fibrous investment of the other bones 
in never becoming ossified. 

Sometimes the morbid action which originates in the syph- 
ilitic infection produces hyperostosis, or thickening and unusual 
induration of the walls of the skull, and more or less irregular- 
ity and roughness of their surface, while at the same time there 
is great thickening and condensation of the pericranium on 
the one side, and the dura matter on the other. I have in my 
possession an interesting specimen of this abnormal condition 
of the cranial bones. 

Rokitansky (vol. iii., p. 198) states that upon a minute 
examination of a section of very compact syphilitic skull, 
numerous Haversian canals were discovered lying far apart, 
and separate groups of unusually large and black corpuscles, 
from which a great number of rays diverged. In a section of 
a piece of syphilitic skull, which appeared porous externally, 
but was in fact very compact, the Haversian canals were found 
wide, the corpuscles mostly large, and some of them" placed at 
right angles to the canals. In the neighborhood of particular 
canals the innermost lamella was transparent, and contained a 
single row of corpuscles, but it was surrounded by a dark 
stratum, interwoven with very numerous corpuscles, which 
were thickly set with rays. 

Instances have been known in which the inner table of the 
bones of the skull and dura mater have been diseased for a 
long time, while the external osseous surface has remained per- 
fectly sound. 



424 GONORRHOEA AND SYPHILIS. 

Exostoses or nodes may arise from the inner surface of the 
cranium, produce compression of the brain, and more or less 
cerebral distress, together with partial paralysis and other 
serious consequences, the cause of all which would not be 
suspected, perhaps, unless a most careful and accurate history 
of the patient were taken into consideration. Sometimes there 
are no other venereal manifestations, and the individual may 
have been exempt from any specific symptoms for several years. 
Nevertheless, if particular inquiry into his past life reveal the 
fact of a former constitutional syphilitic affection, it may fur- 
nish to the investigating mind of the intelligent practitioner 
a clew to the true nature of the case before him, and he will 
form his diagnosis and regulate his line of therapeutics accord- 
ingly. 

In tertiary, or chronic, syphilis, where cerebral symptoms 
have been prominent, tumors have been developed upon the 
dura mater. Sometimes this membrane has been found three 
or four times its natural thickness, the morbid action in such 
instances being like that which attacks the periosteum. In 
some cases arachnitis takes place. In one patient, in whom 
the dura mater and the arachnoid were found to be united, 
Mr. Todd, of London, discovered two large masses of matter 
of a yellow color, like concrete pus, opposite which were cor- 
responding depressions, or concavities, on the surface of the 
cerebral hemispheres ; and at those points the substance of 
the brain was somewhat softened, and also of a redder tint 
than natural. In a second case, Mr. Todd had an opportunity 
to verify his diagnosis, which was founded chiefly on the history 
of the individual and the general symptoms. Besides other 
appearances, the bone of the right temporal region was ascer- 
tained to be much thickened, and a small osseous spiculum was 
seen projecting from the inner surface of the left temporal 
bone.* 

We are also indebted to Dr. Reid, of Belfast, Ireland, for a 
paper detailing the symptoms of intra-cranial syphilitic disease, 
and the triumphant success of the means adopted for their 
removal. In this contribution three cases are related, from 
which we learn that at a remote period or stage of syphilis, 

* London Medical Gazette, New Series, vol. xii., p. 1. 



DISEASES OF THE PERIOSTEUM AND BONES. 425 

paralytic symptoms, with defective intelligence and memory, 
impaired vision, difficulty of articulation, and epileptic seizures 
may set in, and ultimately disappear under proper treatment. 
The means principally relied upon by Dr. Reid consisted in 
shaving the head, extensive blistering of that part, and mer- 
cury. In one of his cases, venesection, active purgatives, and 
tartar-emetic were had recourse to.* 

Mr. Reeve, author of a work on " Syphilitic Meningitis," re- 
ports a case in which there was every reason to believe that the 
patient labored under compression of the brain occasioned by 
syphilitic tumors, developed upon the dura mater. He had 
a paralytic affection, with other cerebral disturbances of an 
alarming character. He could not stand upon his feet ; his 
articulation was imperfect ; his memory and ideas generally 
impaired ; vision in both eyes was disturbed. He was known 
to have had constitutional syphilis a few years previously. The 
scalp was shaved, and covered with a blister, to the surface of 
which mercurial ointment was freely applied for a few days. 
Recovery, took place rapidly. Some of Mr. Todd's cases were 
treated successfully with the iodide of potassium. 

In my own practice I have met with one unequivocal exam- 
ple presenting the leading features appertaining to the cases 
above cited. The iodide of potassium was given largely, for a 
long period, without permanent benefit. The patient did well 
for a time, but afterwards suffered a relapse from which he did 
not recover. He lingered several months in an imbecile 
frame of mind before death took place. Softening of the brain 
was the principal lesion discovered at the autopsy. 

The following case, which occurred at Rainsford Island Hos* 
pital, has been furnished -me by Dr. David W. Cheever, of Bos- 
ton, who was connected with that institution in 1857. 

" Mary R. entered the hospital June 3. She had no chancre 
nor tubercles. Denies a primary sore, but has inflammation of 
cervix uteri, with discharge, and an enlarged gland, not ten- 
der, in the left groin. An eruption of coppery blotches in the 
skin, and also alopecia and hoarseness. She looks pale and 
cachectic. Ordered to have good diet and small doses of iodide 
of potassium ; that is, twelve grains per diem, in syrup of iodide 
of iron. 

* Labatt on Venereal Diseases, 1858, p. 196. 

36* 



426 GONORRHOEA AND SYPHILIS. 

" The eruption was fading, and she seemed going on favorably 
until June 15th, when she was found in the morning hemiplegic 
on the right side. Great difficulty in protruding the tongue and 
in articulating ; the mouth drawn to the left ; the right leg 
quite powerless, and the right arm less so. The other functions 
not affected. 

" Twelve grains of the submuriate of mercury (given grs. iij. 
per diem) sufficed to render her mouth quite sore. She at once 
began to recover power, and at the end of a fortnight could 
move very comfortably. She had no other symptoms ; had a 
good convalescence and restoration of muscular power. 

" Mr. Scolly speaks of the venereal poison often ' putting its 
paw upon the dura mater.' It would seem most reasonable 
to charge this paralysis to one of the freaks of constitutional 
syphilis." * 

Miliary syphilitic tubercles are sometimes developed in the 
bodies of the vertebrae, in the sternum, and in other spongy 
bones. They not unfrequently soften, perforate the bone at 
numerous points in close proximity, and give to it a honeycomb 
appearance. 

Diagnosis. — These tertiary affections, in common with nearly 
all the others appertaining to syphilis, are generally charac- 
terized by peculiar symptoms, which proclaim their specific na- 
ture. If the surgeon have any doubt whether the inflammation 
of the periosteum and bones arises from the venereal element, 
or in consequence of a rheumatic diathesis, all such doubts can 
be put to rest, and an accurate diagnostic conclusion be formed 
by obtaining from the patient his syphilitic history. It must be 
admitted, however, notwithtsanding the contrary is asserted, that 
in some cases simple rheumatic affections and tertiary venereal 
pains have many symptoms in common. It would be strange if 
they had not. Sometimes both diseases, rheumatism and ter- 

* The reader is referred, for further information on this subject, to valuable 
papers written by Dr. John Watson, " On some of the Remote Effects of 
Syphilis" which were published in the New York Journal of Medicine and 
Collateral Sciences, for 1843 and 1845. In these contributions Dr. W. has 
reported several cases of hemiplegia and epilepsy arising from syphilitic 
affections of the cranial bones and then- envelopes, and tubercular deposits in 
the brain. 



■H 



DISEASES OF THE PERIOSTEUM AND BONES. 427 

tiary syphilis, coexist. Mr. Stanley makes the just and impor- 
tant distinction, that while a rheumatic affection occasions gen- 
eral inflammation of the shafts of bone, syphilitic inflammation 
in the periosteum gives rise to circumscribed swelling of the bones. 
If the diagnosis relate to the character of nodes, we should 
never trust to our own skill or self-conceit, nor assume that we 
can distinguish a venereal affection of this description from all 
other local conditions having a similar aspect, but which are 
non-specific in origin. The real nature of a node, independent 
of its history and of any antecedent or concomitant symptoms, 
cannot be determined with certainty by any man. 

Treatment of Tertiary Pains. — When the syphilitic virus 
takes refuge in the deeper organs, as its last hiding-place, it is 
more difficult to control, through the instrumentality of mer- 
cury, than when its manifestations are situated in the superficial 
tissues. Indeed, in proportion as the venereal element pene- 
trates the interior and becomes less accessible, the medicine in 
question seems to be shorn of its ability to do good ; whereas 
the therapeutic action of the iodide of potassium follows the 
opposite rule ; that is, its curative energy is most remarkable in 
those very accidents over which mercurial preparations exert no 
beneficial influence. Hence, for tertiary pains, and all other 
morbid phenomena that follow in their train, the constitutional 
management must consist in the employment of the iodide as 
the principal remedy. But notwithstanding the frequent an- 
nouncement of these facts, there are to be found in the profes- 
sion a few practitioners whose faith in the power of mercury to 
banish tertiary syphilis from the system wanes not, and they still 
prescribe it where the iodide would be vastly more appropriate 
and efficacious. 

Experience has now abundantly taught us that tertiary pains 
are to be expelled, and their recurrence prevented by pretty 
liberal doses of the potassium. At first, eight or ten grains, 
three times a day, in the compound syrup of sarsaparilla, will 
ordinarily be a suitable quantity. This, however, may be in- 
creased, if the physician choose, in the course of four or five 
days, to twice the original amount. 

The topical use of the compound tincture of iodine will be 
attended with benefit. It should be painted on until the skin is 



428 GONORRHOEA AND SYPHILIS. 

made nearly black with the coating of iodine, and the process 

should be repeated every other day. 

Tbe measures above suggested will usually bring the symp- 
toms speedily to a termination. The constitutional remedy 
should, nevertheless, be continued for five or six weeks in small 
doses, even after the individual is rid of them. I advise that 
carbonate of ammonia enter into the prescription, so that the 
patient shall take twenty or thirty grains a day of this salt, or 
even more If these measures fail to bring the desired relief, 
there is but little hope of benefit from any mere medical treat- 
ment. Aconite internally, and also as a topical appliance, 
colchicum, and copious draughts of the sarsaparilla decoction, 
can be tried ; but the results will, in all probability, be unsatis- 
factory. In such cases, which fortunately are very rare, the 
seat of distress is in the interior of the bones, that is, if the 
bones of the extremities are implicated ; and the operation of 
trephining becomes a matter for consideration. This surgical 
measure has been resorted to in repeated instances with entire 
success. A few years since, Mr. Lee, of London, published a 
paper, in which he shows that long-continued pain in a bone 
may depend, among other causes, upon the deposition of solid 
material arising from the venereal poison. He recommends 
trephining for this affection. He operated on a woman, in 
whom the pain and swelling were confined to the neighborhood 
of the knee-joint. As the epiphysis of the bone appeared to be 
the original seat of the complaint, he trephined at that part. 
As soon as the outer shell of bone was perforated, the can- 
cellous structure was felt to give way under the pressure of the 
instrument, and some minute and separate flakes of white mat- 
ter escaped with the blood. The patient recovered.* Mr. 
Langston Parker mentions the case of a woman, in which the 
medullary membrane became inflamed during the secondary 
stage of syphilis. The shaft of the left tibia was the part 
affected. This bone was trephined, and the medullary canal 
opened. The medullary membrane, turbid with black blood, 
which ran from it in a stream, protruded through the opening ; 
the perforation was filled with a piece of soft lint dipped in oil. 
The patient was soon relieved of a most agonizing distress. 
The opening closed with new bone. In about three months 

* London Journal of Medicine, October, 1852. Also Vidal. 



DISEASES OF THE PERIOSTEUM AXD BOXES. 429 

Mr. Parker removed with the trephine a second piece of bone, 
which was carious, and again penetrated the medullary canal. 
No constitutional disturbance followed either operation. The 
woman recovered. 

Treatment of Venereal Nodes. — Patients who are suffering 
from syphilitic periosteal nodes usually manifest progressive 
failure of the general health. Under these circumstances, a 
course of treatment should be adopted that will tend to recruit 
the vital powers. The utility of mercury was once believed to 
surpass that of all other drugs in the various stages of periosti- 
tis ; but of late years the attention of medical men has been 
favorably attracted towards the iodide of potassium, and now 
the voice of the profession is, with here and there an exception, 
in favor of this article, as the most reliable agent we can 
employ, with a view not only of subduing tertiary pains, but 
also for the more important purpose of causing the absorption of 
the morbid deposit, and thus greatly to diminish the chances of 
active inflammation and its direct ulterior consequences, ex- 
foliation of the subjacent bone. All these indications, as re- 
gards the local disease, can be accomplished, and no permanent 
traces of its visitation remain, and in the mean time the consti- 
tutional state of the individual will be improved by the same 
measures. Persons who have long been troubled with peri- 
ostitis, become exceedingly pale and chlorotic — a circumstance 
indicative of serious impairment of the composition of the 
blood. The most important deterioration consists in the dimi- 
nution of the red corpuscles. The process of reduction in the 
relative proportion of globules commences early in the venereal 
history of the patient, and continues during the progress of 
his malady, until at length it terminates in the exsanguine 
condition alluded to. These facts furnish the practitioner witli 
an important principle in a therapeutic sense. They make 
known to him the reason why the preparations of iron are so 
beneficial, and so eminently entitled to confidence in chronic 
venereal disorders. For the purpose, therefore, of restoring the 
equilibrium of the elemental constituents of the vital fluid, and 
of enabling the system more speedily to regain its wonted tone, 
the class of remedies now referred to may be advantageously 
united with the iodide of potassium. Of all ferruginous com- 



430 GONORRHOEA AND SYPHILIS. 

pounds, the potassio-tartrate is the most valuable. It exerts 
a prompt influence in enriching the impoverished sanguineous 
fluid, and restores it nearly to its healthy physiological standard ; 
it works in perfect harmony with the potassium, and in most 
cases which fail to derive the anticipated benefit from the latter 
substance, the tartrate can be brought into service as an im- 
portant tributary. 

In case of recurrence of ancient periosteal affections, — and 
this is not very uncommon, — the iodide is again to be pre- 
scribed, until the symptoms once more yield. A full, generous 
diet, pure air, and frequent bathing, will likewise essentially 
inure to the benefit of the patient. 

While it is a well-established fact, that the potassium exerts 
almost a specific influence on the hard periosteal nodes, it is 
equally certain that when suppuration has commenced this 
salt possesses little or no virtue, so far as relates to the local 
disease. If there be a marked syphilitic cachexia, with en- 
feebled nutrition, emaciation, and depreciation of the whole 
organism, and the surgeon see fit to continue its use in small 
doses as a general tonic, there is no objection to the treatment ; 
although in such a juncture the iron will be found more effica- 
cious. Whether a solution of the potassium or the iron be 
ordered, it should be taken in a large quantity of the compound 
decoction of sarsaparilla. 

Mercury. — Notwithstanding our repugnance to the use of 
mercury in this complaint, and our confidence in the iodide of 
potassium, instances will present themselves for the cure of 
which the former medicine will be required as a small fractional 
part of the treatment. For instance, if there be a goodly share 
of constitutional vigor, and if the antecedent symptoms have 
been treated entirely by what is termed the " simple method," 
the practitioner will do well to institute a short mercurial course, 
and especially will this plan be judicious if there be much local 
inflammation. But as soon as this has been subdued, the potas- 
sium, together with some chalybeate, should be substituted. 



DISEASES OF THE PERIOSTEUM AND BONES. 431 



LOCAL TREATMENT OF NODES. 

If much inflammation exist in the integument, a few leeches 
near the nodular tumefaction will be proper. Afterwards, 
blisters, and the compound tincture of iodine, repeated suf- 
ficiently often to keep the skin perfectly raw, will constitute the 
most suitable topical means we can put in force. Or the 
denuded surface may be dressed with the Emplastrum ammo- 
niac! c. hydrargyro, or with the strong mercurial ointment. If, 
notwithstanding a judicious employment of the measures here 
recommended, the node continue to increase, and seem tending 
towards suppuration, or if that event have already taken place, 
the surgeon need not wholly despair of accomplishing the ab- 
sorption of the fluid, which is sometimes effected under very 
unpromising circumstances. However strongly he maybe in- 
clined to set free the purulent collection, he should delay the 
operation until all rational hope of absorption is abandoned. 
The opening of a node is very liable to be followed by most 
unpleasant consequences. Should the practitioner decide to 
puncture the abscess, as a last resource, a very fine trocar, 
rather than a lancet, should be the instrument ; and every pre- 
caution should be observed to prevent the entrance of air into 
the wound. The danger of caries and exfoliation of the sub- 
jacent bone will thus be essentially lessened. 

A case now and then transpires, in which the morbid growth 
has been of long duration, and after undergoing a certain 
degree of diminution remains nearly stationary, is of bony hard- 
ness, and is attended with no pain or other inconvenience. 
It is an instance of real osseous deposit — an exostosis, which 
will be uninfluenced by any medical agents. It is the result of 
the previous inflammatory action in the bone and periosteum, 
and, unless it should interfere with the normal functions of 
the related organs, it may be allowed to remain on the part 
as a mere excrescence and harmless deformity. 

In whatever portion of the osseous system exfoliation, caries, 
or necrosis takes place, under the influence of the syphilitic 
virus, the surgical and medical treatment is to be the same as 
under circumstances wholly independent of such a cause ; and 
any suggestions from me relative to the management of these 
conditions seem uncalled for. 



CHAPTER XXXIX. 

INFANTILE SYPHILIS. 

The transmission of the syphilitic materies morbi from parent 
to child has long since ceased to be a subject of doubt. But it 
does not follow that the offspring of venereal parents will, as an 
absolute matter of course, exhibit specific symptoms during the 
infantile period of its existence. The development of such 
phenomena may be postponed for several years, even until the 
child reaches adult age. Such cases are known as hereditary 
syphilis. In some rare instances the taint never shows itself. 
Immunity, however, is but the exception to the rule. 

In April, 1855, a young woman, whom I was attending for 
constitutional syphilis, gave birth to a plump, healthy child, 
which is now more than nine years old, and has thus far been 
free from all specific affections. During gestation the mother 
suffered greatly from general debility, and was sadly afflicted 
with tubercles, pustules, and cutaneous ulcers. The primary 
disease in this woman was derived from the father of the child, 
and happened as early as 1850. Both parents had secondary 
symptoms ; the mother for more than four years, when tertiary 
lesions were also developed. For a short time she nursed her 
infant, but, the natural fountains failing to yield the needful 
supply, it was placed in charge of a healthy wet-nurse. What 
destiny awaits this child, in regard to the syphilitic taint, time 
must show ; but that the offspring of such parentage should 
have remained so long exempt from its manifestations, is not a 
little extraordinary. 

The features which the syphilitic disease presents in the young 
infant are quite different, in many respects, from those developed 
in the adult. Especially is this remark applicable to the morbid 
appearances which show themselves upon the external surface ; 
and this imperfect resemblance offers one of the greatest difficul- 
ties we meet with in clearing up the obscure points, which not 

(432) 



DISEASES OF THE PERIOSTEUM AND BONES. 433 

unfrequently baffle the judgment, in our attempts to decide 
upon the exact pathological character of the symptoms under 
review. In the adult subject the phenomena are developed 
with comparative regularity, and are generally recognized at 
sight. The origin or mode of infection in the two classes of sub- 
jects is different, and the lesion which is primary in the one, is 
rarely ever met with in the other. M. Caillault, a recent French 
writer, considers the cutaneous phenomena of congenital syphilis 
as constituting in point of fact the whole disease of infants.* 
This view of the subject, however, is untenable, as we shall 
shortly see, and as almost every physician already knows. 

In infantile syphilis the symptoms belong almost exclusively 
to the secondary group. The tertiary affections, involving the 
bones and their immediate investments, are very rarely met with. 
A few years since, Dr. Yan Buren, of New York, had' a case of 
this sort; and M. Bertin has given an instance that occurred at 
la Maternite nearly half a century ago, and in a child thirty- 
five days old. There was periostitis on the superior and poste- 
rior surface of the ulna ; tubercular pustules sprang up on 
various parts of the surface ; and a tumor, as large as a pigeon's 
egg, formed over the left great trochanter. Small doses of cor- 
rosive sublimate were administered, and in three or four months 
all the symptoms disappeared. 

The bones of the nose in the new-born infant are occasionally 
destroyed by the disease, and a falling in of the organ takes 
place, which imparts to the features a most hideous deformity ; 
and Dr. West records the case of an infant of a few months old, 
whose bony palate was destroyed. 

If the father have at any period been afflicted with primary 
disorder, but is free from consecutive lesion when the ovum is 
impregnated, the product of such impregnation may, never- 
theless, be tainted with constitutional syphilis. Here the pro- 
creative element is the medium of transmission. Results of this 
description are extremely rare, but the' bare fact of their oc- 
currence is established beyond all possibility of doubt. Within 
a twelvemonth I have met with one example perfectly well 
authenticated. The child began to show evidence of the vene- 

* A Practical Treatise on Diseases of the Skin in Children from the French 
of Caillault. By R H. Blake, &c. London Edition, 1863, p. 6. 
37 



434 GONORRHOEA AND SYPHILIS. 

real taint when three weeks old. But its true condition was 
not understood by the parents, and no apprehension of its 
safety was entertained until the surface of the body and limbs, 
and a portion of its face and head, were thickly covered with 
scaly blotches of undoubted specific eruption. The father, a 
well-educated legal gentleman, took alarm, and made known to 
me his history, stating that several years before marriage he 
contracted chancre, but never had constitutional symptoms. I 
saw the child but once. It was a living mass of corruption, 
and died before it reached its tenth week. The mother escaped 
contamination, and had no suspicion of the real malady that 
destroyed her first-born child. She did not nurse it. 

Where one instance occurs like that of the child above men- 
tioned, there are hundreds, probably thousands, where no taint 
is communicated by the spermatic secretion of the father, who, 
at a former period, may have had chancre, but in whom no 
constitutional complaint exists at the time the ovum is impreg- 
nated. The explanation of these facts must, in the present 
state of our knowledge, be purely hypothetical. In the instance 
I have adduced, the father, as he stated to me, was subjected to 
the simple method of treatment for his chancre. Had mercury 
constituted the chief remedy, would the child have escaped the 
infection ? Whatever may be the true answer to this inquiry, 
I deemed it expedient to put this father upon a moderate mer- 
curial course, combined with diaphoretics, the use of which 
was prolonged for several months, with a view to eliminate the 
latent poison, and thus prevent its transmission, in the event of 
any future pregnancies through his instrumentality. The re- 
sult of this treatment has not yet transpired. My confidence 
in it is not very great. 

The blight of the ovum and abortion are often produced by 
the presence of the syphilitic virus derived from the vitiated 
spermatozoa of the father, who, as well as the mother, may be 
in good health at the time of the conception. By some writers 
it has been supposed that in these cases the mother must be 
infected first, and the fcetus afterwards ; but facts are every 
now and then brought to light disproving this theory, and estab- 
lishing exactly its opposite, namely, that the mother, who es- 
capes the infection at the time of copulation with an individual 
laboring under the venereal diathesis, may become infected 



INFANTILE SYPHILIS. 435 

from the foetus, the germ of which has been poisoned by the 
semen of this same individual. This proposition may be con- 
sidered as established by indubitable facts which have been 
announced by the most reliable observers. I must here cite 
an instance related by Mr. Langston Parker at a recent lecture 
at Queen's College, London. A man married a healthy lady, 
having had no symptoms of syphilis of any kind for a year pre- 
vious to his marriage. Shortly after marriage his wife became 
pregnant, and the husband again suffered from copper-colored 
blotches on the skin, and he had ulcers in the throat, and lost 
his hair and eyebrows. The wife was prematurely delivered, in 
the fifth month of her pregnancy, of a dead child. She had, 
about this time, copper-colored blotches like her husband, a sore 
throat, and lost her hair and eyebrows. In this case, and I 
dwell especially on the fact, says Mr. Parker, no sexual mis- 
chief existed. The wife was carefully examined. She had never 
had a vaginal discharge of any kind ; the vagina and the mouth 
and neck of the uterus appeared totally free from disease.* 

In considering the facts connected with the etiology of infan- 
tile syphilis, there is no difficulty in comprehending the influ- 
ence of a syphilitic mother in transmitting the same malady to 
the new being that germinates in her womb. The mystery is 
rather how the bud or branch that springs from such a trunk 
can possibly escape. During the intra-uterine existence of the 
child it derives its pabulum — its life-blood — from the same 
vivifying current that supplies the maternal organism, and it 
would be strange indeed if, during this imprisonment and this 
condition of utter dependence, it did not imbibe into its tissues 
the same morbid element that preys upon the mother. 

Probably the circulation constitutes the most common me- 
dium, or channel, through which the venereal poison is con- 
veyed to the foetus in utero, although Hunter entertained the 
hypothesis that the blood could not infect, and therefore he 
could not comprehend how the foetus was contaminated. 

The infection can be communicated during parturition by 
the infant passing through the vagina affected with primary 
venereal ulcers. Inoculation in this way, however, is probably 
very infrequent. The smegma, or sebaceous matter, that coy- 

* Lancet, May 29, 1858. 



436 GONORRHOEA. AND SYPHILIS. 

ers the whole surface of the child, operates as an admirable 
safeguard. Vidal questions whether primary chancre has been 
observed in the new-born infant, produced by disease in the 
genital passages of the parturient mother. 

There is also reason to believe that the milk of a syphilitic 
nurse is sometimes the medium of infecting the nursling, 
whether the breast is the seat of any local disease or not. 
This opinion is entertained by Mr. Whitehead,' Mr. Wilson, and 
other writers of note, but is denied by other high authorities. 
I imagine that no practitioner would, if called upon for advice, 
recommend a suckling child to the custody of a syphilitic wet- 
nurse, knowing her to be such. Such counsel, if given by a 
physician in this country, would be suicidal to the professional 
reputation and standing of its author, and that justly. lie 
might as well countenance the deadly administration of arsenic 
dissolved in the contents of the milk-bottle, as to allow a child 
to draw poison from the human breast. 

An infant, having secondary symptoms at birth, cannot infect 
its mother's breasts, even if its mouth be ulcerated, although 
such a child can, and often does, inoculates strange wet-nurse. 
The late Mr. Colles, of Dublin, was the first to discover and 
furnish to the profession this curious fact. His statement has 
been corroborated by others who have had ample opportunities 
for observation. Mr. Hutchinson, surgeon to the Metropolitan 
Free Hospital, London, gives full countenance to the views of 
Mr. Colles, and suggests, in explanation, that in such cases the 
mother of the diseased child has already received from it, whilst 
in vleroy all the contagion it is capable of conveying. Hence 
her exemption or immunity. 

Prognosis. — If the child be seen early, and can be placed 
under favorable hygienic and remedial influences, the prognosis 
in many cases is quite favorable. It is a fact, however, in a 
majority of instances where the disease is congenital, — that is, 
where the infant comes into the world with the syphilitic leaven 
pervading its organization, — that it is endowed with alow vital- 
ity, and that its existence is very seriously compromised. Al- 
though for a few days or a few weeks all may seem fair and 
promising, death will very probably overtake the poor victim 
before it arrives at the period of dentition. 



INFANTILE SYPHILIS. 437 

The most fatal epoch is before the child reaches the third 
month of extra-uterine life. 

If contamination take place after birth, the case is one of 
acquired syphilis, in distinction from congenital or hereditary 
disease, and the prognosis is more favorable than it can be 
where the taint is coeval with conception, or with any portion 
of foetal existence. The symptoms are usually of a mild type, 
and yield to good nursing, cleanliness, pure air, and gentle 
medicinal treatment. If inoculation with chancrous matter 
have taken place, which, as previously stated, is an exceed- 
ingly rare occurrence, the resulting sore is more apt to assume 
a phagedenic character than in the adult. 

Symptoms. — Infants born with the venereal taint within 
them exhibit, for the most part, great uniformity of symp- 
toms ; and yet there is not, in every instance, an entire assem- 
blage of all the morbid phenomena which the virus is known to 
engender. In some cases, where the constitutional infection is 
contracted during embryonic life, the manifestation of all spe- 
cific accidents or lesions is delayed for several months ; the 
infant, meantime, being to all appearance in perfect health, 
until some incidental circumstance, such as dentition or the 
process of weaning, seems to operate as an immediate exciting 
cause in bringing to light the latent diathesis. Generally, how- 
ever, it may be remarked that the effects of the poison are well 
pronounced at an earlier period.* If you look at a child three 
or four weeks old, that has the virus within it as a transmitted 
inheritance, the first thought that suggests itself is that you 
have before you a miniature emblem of old age. The integu- 
ment of the face and of the whole frame is wrinkled in conse- 
quence of defective nutrition. It hangs in little folds about the 
jaws, neck, and different parts of the limbs, and is of a dirty 
yellow tint. This peculiar color of the skin Trousseau consid- 
ers of great value in forming a diagnosis* He attaches more 
importance to it than to the copper color of eruptions. Within 
the past ten years I have had opportunity to examine great 



* The data, obtained by Diday from various sources, show that out of one 
hundred and fifty-eight eases, eighty-six presented symptoms before the first 
month, forty-five before the second month, and fifteen before the third month. 



438 GONORRHOEA AND SYPHILIS. 

numbers of foundlings and other young infants, in whom the 
venereal impregnation manifested itself by the presence of this 
unique, cutaneous pigment, as one of the earliest, most constant 
and significant abnormal conditions visible. It is frequently 
present before any actual eruption appears upon the external 
surface, and before the mucous membranes exhibit any marked 
signs of specific disease. Remarkable and characteristic 
blotches, having the well-defined, coppery hue, are especially 
frequent about the buttocks, thighs, genitals, legs said abdo- 
men. 

The integument of the hands and feet presents* an erythe- 
matous congestion, with numerous traces of exfoliation of the 
cuticle ; and fissures of various depth, and ulcerations mostly 
superficial, are formed in the natural flexures of the fingers 
and toes, at the roots of the nails, and elsewhere on these parts. 
A similar appearance of the skin will generally be noticed on 
examination of the nates, the perineal and anal regions, tha 
scrotum and labia. 

The surface often has a mottled aspect, not unlike that of 
rubeola. It is, however, of a darker hue than that of ordinary 
measles ; it comes at first in small circular discs on the forehead 
and checks, or about the chin, or below the ears, and resembles 
mere flea-bites in appearance. In four or five days, nearly the 
whole of the face, the neck, the chest, and abdomen, will be oc- 
cupied by them. These blotches of eruption are quite persist- 
ent, and are frequently accompanied by a general anasarcous 
state, which imparts to the skin a smooth polished aspect. This 
morbid condition has been called rubeola syphilitica. 

Syphilitic maculce frequently arise upon various districts. 
They are of different dimensions, and assume an oval or round 
figure and the well-known coppery color. They subside par- 
tially under the pressure of the finger. In some cases, a slight 
desquamation, as in chloasma, is perceptible in connection with 
these yellow stains, and in others not. [Plate YIL] 

If the morbid patches become decidedly squamous, it will 
be found, on examination, that this condition is preceded by a 
crop of minute papules, which spring up on the inflamed spots, 
and pultaceous scales are afterwards evolved on the apices of the 
papules. The portions of skin thus implicated usually increase 
in size by new accessions of papules appearing on their borders, 



PLW 



Maculae 




Syphilitica 



pl -mi. 




Psoriasis Orbicularis Syphilitica 



INFANTILE SYPHILIS. 439 

which are elevated above the adjacent surface. They assume 
and maintain a pretty uniform orbicular figure. [Plate VIII.] 

hi some instances the eruption is confined to the hands and 
feet, in the form of well-defined, copper-colored squama?, while 
all the other portions of the integumenj are free from blemish. 

Sometimes the eruption manifests a marked pustulo-papular 
tendency. The amount of exudation, however, is small, and 
produces irregular, thin, dark-colored incrustations, which are 
very adherent to the subjacent derma. Superficial sores often 
break out also about the knees, the ankles, shoulders, and other 
parts, that are exposed to pressure or friction. Fissures are 
likewise very generally seen at the angles of the mouth in such 
children, and a sort of psoriasis of the lips, which are dry and 
parched; and the little sufferer seems to keep the mouth com- 
pressed instinctively, as if for the purpose of avoiding constant 
distress in the parts. Isolated mucous patches are often observed 
in the same localities as in the adult ; so also the lining mem- 
brane of the mouth, the throat, and nasal passages, participates 
in the specific lesions ordinarily entailed upon older persons. 

In certain cases the morbid affections of the mucous mem- 
branes exist some little time before any abnormal condition of 
the cutaneous structure is noticed ; in others, the mucous tissue 
apparently receives nearly the whole force of the disease, while 
the skin remains intact, or nearly so. The congestion and in- 
flammation of the pituitary membrane always interfere with 
respiration, especially when the child is at the breast. The 
peculiar breathing on these occasions attracts the notice of the 
mother or nurse, who reports that the child has " the snuffles," 
— an expression familiarly known and very suggestive to the 
medical attendant. As the morbid action progresses, the breath- 
ing becomes more laborious and obstructed, and the patient has 
no little difficulty in swallowing its nourishment. It chokes 
and struggles, and fitfully quits the nipple for the moment. 
The disease penetrates downwards ; the larynx soon becomes 
implicated, and the voice has a singular but characteristic 
stridulous tone when the child attempts to cry. Sometimes 
the cry is hardly audible, or, if heard, amounts to a mere 
hoarse, squeaking sound that is scarcely human. 

There is a discharge from the nose of an offensive, sanio- 
purulent secretion, intermingled with mucus. This irritates 



440 GONORRHOEA AND SYPHILIS. 

the integument, and concretes into scabs about the nasal aper 
tures, thus materially increasing the discomfort of the child. 
The mouth is dotted over with white aphthae and superficial 
ulcerations ; and if nothing be done by way of treatment, the 
whole lining-membrane becomes involved, and secretes a thick, 
acrid, heterogeneous fluid, which has been known to occasion 
excoriations, or still more serious disease on the nipples of the 
wet-nurse. After the morbid processes have existed in the 
mouth for a short period, a relaxed state of the bowels is apt 
to supervene. This, of course, augments the general disturb- 
ance of the child's constitution, and it soon fails to take the 
requisite nourishment, sinks rapidly into a pitiable condition, 
and dies greatly emaciated. Such are the symptoms, and 
such is the result, where the malady is allowed to pursue its 
own course, as is often the case among the lower ranks of 
society. 

Some children, that come into the world imbued with the 
syphilitic poison, perish before any specific symptoms show 
themselves on the skin or mucous membranes. They have been 
badly nourished in utero, are feeble, squalid, and wasted in flesh 
to the last degree. They take the breast with indifference, or 
perhaps scarcely at all ; they survive but a few hours or days, 
and then die of starvation, and without exibiting any evidence 
of suffering. 

Iii some instances the syphilitic infant will remain quite 
thrifty until it arrives at the age of eighteen or twenty months, 
when a specific eruption will break out here and there upon 
the body and limbs. Where the appearance of the cutaneous 
affection is deferred until the period here mentioned, it is likely 
to come in the shape of well-defined tubercles or papules ; 
whereas, in the child of only a few weeks, the abnormal con- 
dition of the surface usually presents a squamous type only. 
The tubercular or papular masses are most commonly abundant 
about the folds of the neck, the inguinal region, the labia, the 
scrotum, perinaeum, and anus. Specimens of the true mucous 
tubercle, occupying the same localities as in the adult, are occa- 
sionally met with in these young subjectSo The external erup- 
tion is accompanied with extensive lesions within the mouth. If 
the child be so fortunate as to be well fed, its general health will 
frequently continue good for three or four months after the 



INFANTILE SYPHILIS. 441 

advent cf the phenomena above described, even if no treatment 
be instituted. 

Erythema. — As yet we have barely mentioned this exan- 
them. As it is generally the precursor or rallying point of other 
venereal eruptions, it is invested with an interest which would 
not otherwise attach to it. It may be well therefore to dwell 
upon its features for a moment. Its presence is of grave im- 
port. It denotes that there is a profound constitutional disturb- 
ance, of which the eruption itself is a mere sign or expression 
not produced by any local or extraneous cause. The eruption 
may appear on any part of the body or limbs, but seldom comes 
upon the face. It assumes for the most part an acute form, but 
apparently produces only slight discomfort to the child. It 
spreads out upon the surface in somewhat irregular circular or 
oval patches of various dimensions. 

At first the color is a vivid red, but in two or three days the 
blotches reach their acme, and the brilliant scarlet hue becomes 
gradually less conspicuous, and a dingy red color prevails. 
After the erythema has continued for six or eight days, a delicate 
trace of yellow often mingles with the coloration. 

If the eruption exists upon the nates, around the anal re- 
gion, inguinal folds, or genitals, the cuticle is very apt to be cast 
off at an early day, and after the desquamation has taken place 
the derma shines as if polished or covered with a layer of var- 
nish. There is little or no serous exudation, except about the 
folds of the skin. The cuticle is reproduced at irregular inter- 
vals, and if the child nurses well, is kept cleanly, enjoys a salu- 
brious atmosphere, is brought under the immediate action of 
appropriate medicine, — that is, mercury, — and the venereal 
diathesis is comparatively mild, it may resist any further en- 
croachments of the disease 

I have now under treatment a female infant, nine months old, 
which first exhibited, at the age of five months, signs that it 
inherited the venereal diathesis. The mother has never suffered 
from the complaint, but she knows the father has. At first, 
erythematous blotches of moderate dimensions came here and 
there upon the extremities of the child. They were not numer- 
ous, but the mother suspected their nature. In a few weeks 
small isolated tubercles supervened. These soon acquired a 



442 GONORRHOEA AND SYPHILIS. 

pustular character, with hard bases and thick, dark, prominent 
scabs ; presenting, in short, the usual features of syphilitic 
ecthyma. The mucous surfaces were not abnormal. The 
general aspect of the child, when I first saw it, betokened a 
moderate degree of atrophy or stinted growth. It lacked vi- 
vacity, plumpness and color. It nursed well but the nutritive 
function was at fault. That it was a genuine case of congenital 
syphilis there was no reason to question. 

The child was put upon the use of the bichloride of mercury, 
— one-sixtieth of a grain twice a day, — and to the eruption a 
weak nitric oxide of mercury ointment was applied. The erup- 
tion yielded very rapidly to the action of the medicines, and the 
child has grown fat and in all respects improved in a satisfactory 
manner. The bichloride will be continued in half the original 
quantity for some weeks to come. 

But in a vast majority of cases a far different doom awaits the 
syphilitic child. The morbid phenomena, instead of diminish- 
ing in severity, become more and more intense ; the erythem- 
atous inflammation bursts out in new places, and spreads in 
every direction ; excoriations of various extent and depth are 
formed; gangrenous or sloughing ulcerations are established at 
different points ; numerous vesicles or bullae appear about the 
small joints of the extremities and discharge a foetid, sero-sanious 
matter ; the ill-developed nails turn yellow, dry up, and are 
detached ; abscesses supervene, and diarrhoea sets in ; and finally 
coryza and laryngitis complete the picture, and the child dies. 
I have seen not a few such cases within the last thirty years. 

INTERNAL ORGANS 

The Lungs. — Indurated masses or nodules arc frequently 
found in the parenchyma of the lungs in all stages of development 
as a syphilitic lesion. At first they are hard, — mere indurations ; 
they afterwards soften, suppurate, and yield a .sero-purulent 
fluid. Their course is usually rapid and always fatal. The 
symptoms to which they give rise are similar to those of pneu- 
monia. The pulmonary affection is occasionally the only disor- 
ganization manifest, but in most instances the skin, the throat, 
and other regions, are occupied by some allied form of syphilis. 
These nodules are formed during foetal life, and have been found 



INFANTILE SYPHILIS. 443 

by M. Tierlinck to contain pus-globules at the seventh month. 
It still remains a matter of question whether a true tuberculosis, 
either in the young or In the adult subject, can be produced or 
even developed by the syphilitic element. 

As yet we have no means of positively detecting the peculiar 
elementary characteristics of these syphilitic deposits, if any 
such really exist. The microscope brings to view fibro-plastic 
material, cell-nuclei of various sizes, oil or fat globules, pus 
globules, amorphous matter, <fec. ; but these are all found in 
other morbid products also. In the early stage of formation 
Mr. Wilks, of Guy's Hospital, found nodules in the lungs of a 
syphilitic patient to consist of fibro-plastic tissue. The disease 
in this instance consisted of rounded masses in the substance of 
the lung, quite circumscribed and firm, and presenting an 
appearance different from the ordinary or inflammatory deposits. 

Several writers have described diseases under the term 
" Syphilitic Pulmonary Disease ; " and one author tells us that 
syphilis displays itself in the lung under the varied forms of 
bronchitis, pneumonia, or broncho-pneumonia. 

Hepatic Affections. — It has for a long period been a well- 
settled belief that in constitutional syphilis the liver becomes 
involved ; and it is now fully demonstrated by pathologico- 
anatomical facts that the venereal poison is one of the most 
frequent predisposing causes of various morbid conditions of the 
biliary apparatus. The morbid process manifests itself in several 
different forms, as simple interstitial hepatitis, hepatitis gum- 
mosa, waxy, amyloid or lardaceous degeneration of the liver. 
There are still other forms of hepatic disease where the devel- 
opment of areolar tissue is widely extended throughout the liver, 
and gives rise to simple or granular induration, and are 
described under the title of syphilitic cirrhosis. 

Of seventeen cases of syphilitic hepatitis examined by Frericks 
the organ was reduced in size four times, and once it did not ex- 
ceed twice the size of a man's fist ; the volume was normal in seven 
cases, and in six it was enlarged ; in five there was waxy degen- 
eration. This latter condition, resulting from constitutional 
syphilis, may exist when the osseous system is not attacked. It 
has been found even in newly born infants. 

In the year 1848, M. Gubler, of France, presented to the 



444 GONORRHOEA AND SYPHILIS. 

notice of the profession a very important paper demonstrating 
the occurrence of a peculiar change in the liver in a great num- 
ber of new-born children affected with hereditary syphilitic 
phenomena; and the pathological researches .of Cullerier, 
Depaul, Lebert, Trousseau, and many other observers, concur in 
proving that while various syphilitic lesions are developed in 
the skin and mucous membranes, the liver is profoundly dis- 
organized in different ways ; but the most frequent abnormal 
conditions appear to be hypertrophy and induration ; and yet, 
strange to say, Mr. Wilks informs us that although he has seen 
fibrous deposits in the livers of children who have had heredi- 
tary syphilis, he has not met with this enlargement and hard- 
ness of the organ. The change here spoken of is regarded as 
similar to the lardaceous or waxy liver. In extreme cases of 
this extraordinary formation it resists pressure, and when torn 
by the fingers its surface receives no indentation from them, and 
the elasticity of the organ is such that if a wedge-shaped piece 
taken from its thin edge be pressed, it escapes like a cherry- 
stone and rebounds from the ground. When cut into it creaks 
slightly under the scalpel. Sometimes the change is universal, 
at other times partial. 

Microscopical examination of the diseased tissue reveals the 
presence of a great amount of fibro-plastic material. 

A remarkable fact connected with this syphilitic condition of 
the liver is, that there is never any jaundice even when the 
entire organ is diseased. 

Gubler regards the special change in the liver above spoken 
of as a lesion of the tertiary order, although no tertiary phe- 
nomena, properly so called, are observed to coexist with it ; and 
further, it has been found that the iodide of potassium will not 
cure it, while the proto-iodide of mercury has been found to be 
the specific for it. The opinion of Diday is quite curious, and is 
at variance with that of Gubler. Diday believes (p. 95) that 
the induration of the liver in new-born children is exactly anal- 
ogous to the induration of a chancre in the adult, and is due to 
the transmission of the poison furnished by the blood of the 
mother, determining in its course the same organic reaction, of 
which induration is the expression, which the poisonous pus 
absorbed during coitus induces around the chancre, and then in 
the first lymphatic which it traverses. On this theory induration 



INFANTILE SYPHILIS. 445 

of the liver ought not to occur when the infection proceeds from 
the father ; and such, it is averred, is the fact.* 

Treatment. — So far as mere pharmaceutic agents are con* 
cerned, the treatment may be summed up in few words, namely, 
mercury and the iodide of potassium. The same may be said 
in regard to the treatment of syphilitic lesion of the lungs, 
although in the latter malady no therapeutic preparations are 
available for good. The form of mercury which I prefer is the 
bichloride, — from one-sixtieth to one-twentieth of a grain once 
or twice per diem, as in the subjoined formula : — 

K. Hydrargyri Bichloridi, .......... gr. j. 

Syrupi Tolutani, § ss. 

Aquae Fontanse, § viiss. M. 

Give a teaspoonful, once, twice, or thrice daily. 

In regard to the duration of the mercurial treatment no 
positive rules can be prescribed. The age of the child, the 
severity of the symptoms, and the apparent influence of the 
remedy, will serve, in a good degree, as a rational guide both 
as to the daily amount that should be administered and the 
period during which it should be continued. It should be pro- 
longed for two or three months, with occasional intermissions of 
a few days, after the syphilitic manifestations have disappeared. 
It must not be concealed, however, that the prospect of perma- 
nent benefit to the little patient is very slight, compared with 
the many probabilities to the contrary. 

* Testelin, a German writer, comes to the following conclusions respecting 
syphilitic affections of the liver. (1.) In a majority of cases the high mortality 
of sucking children, affected with hereditary syphilis, depends on specific dis- 
ease of the liver. (2.) This morbid alteration, characterized in the dead body 
by the presence of fibro-plastic elements in the parenchyma, reveals itself dur- 
ing life by disturbance of the digestive canal coexisting with the ordinary 
signs of hereditary syphilis, and by a considerable enlargement, of the liver 
demonstrable by palpation or percussion. (3.) In most cases of syphilitic 
affection of the liver death is caused by a suddenly supervening of peritonitis. 
(4.) In rare cases death can also be caused by passive hemorrhages, which 
may depend partly on the crasis of the blood, partly on the disturbance of the 
circulation occasioned by the liver affection. — New Sydenham Societyls Year- 
Book of Medicine and Surgery for I860, p. 238. 
38 



446 GONORRHCEA AND SYPHILIS. 

Peritonitis. — Several years ago, Professor Simpson reported 
a number of cases of this disease which proved fatal in children 
whose mothers were suffering from constitutional syphilis, and he 
considered the peritoneal inflammation as due to the venereal 
element. Gubler states that in some cases of infants in whom 
induration of the liver was found, evident traces of inflammation 
of the peritoneum were also detected. 

Thymus Gland. — Numerous instances of suppuration of 
this organ in children of syphilitic parents have been reported 
by various observers. Externally the gland presents no abnor- 
mal features ; but upon cutting it open and squeezing it, minute 
drops of purulent matter appear upon the incised surfaces. In 
most of the subjects thus examined, the skin, lungs, and liver 
likewise presented unequivocal evidence of syphilis. 

Diagnosis. — By studying the specific accidents, the physician 
will soon be convinced that the child has upon it symptoms and 
appearances not belonging to any non-venereal malady. 

The child may be born at the normal period of gestation. It 
may, possibly, be plump and hearty, and no signs of disease be 
manifest for several weeks after it comes into the world ; when, 
suddenly, it will furnish indubitable proof that it is the offspring 
of syphilitic parents. The salient points, which, for the most 
part, present themselves for examination and study, have already 
sufficiently engaged our attention. 

Infants a few weeks or months old are subject to eczema on 
the face, the scalp, and extremities. But however severe this 
troublesome affection may be, it is very seldom indeed that the 
general health of such young children is impaired. They have 
restless nights, because of the ceaseless pruritus that charac- 
terizes the affection, but they feed and thrive as well as if no 
cutaneous eruption were upon them ; nor have they any corre- 
sponding abnormal state of the buccal and nasal mucous mem- 
brane. They can cry with a clear and strong voice, and are 
generally extremely fractious ; whereas syphilitic infants are 
usually just the reverse, and to a remarkable degree, for the 
reason that they do not suffer from cutaneous irritation, how- 
ever extensively the skin may be covered with specific eruption. 

Strophulus confertus is quite a common eruption among 



INFANTILE SYPHILIS. 447 

infants during early dentition. It appears upon the cheeks, 
upon the dorsal aspect of the extremities and trunk. Although 
the elementary form of the rash is a papule, the general appear- 
ance of the skin and of the patient has nothing in common with 
the features observed in a syphilitic papular eruption at this age. 
Besides, strophulus like simple eczema, occasions a good deal 
of itching, and prevents the quiet sleep of the child, which, 
however, usually enjoys high health, and the pimples disappear 
in a few months as well without medical assistance as with it. 

It has been sufficiently shown that a venereal complaint de- 
veloped upon the skin of an infant is almost without exception 
associated with disease within the mouth, and with constitu- 
tional derangement of a very grave character. Let this impor- 
tant fact always be fresh in the mind in all cases that present 
themselves for our decision as to whether they are syphilitic 
or otherwise, and we shall rarely misjudge the nature of the 
disease. 

Another important general fact or circumstance due to the 
venereal poison, when pervading the foetal economy, is the de- 
fective performance of the function of nutrition ; and it is to 
this imperfect developmental action continually operating upon 
the embryonic organization, that we are to attribute the 
withered, senile condition of the majority of children born 
under the evil star of syphilis. Mr. Hutchinson is of opinion 
that in those instances where the infant is born apparently well, 
but showing signs of syphilis soon after birth, the taint is 
derived solely from the father. The mother, being free from 
disease, furnishes a supply of healthy nutriment to the foetus, 
which lives and thrives, having no need for the exertion of its 
own organs of assimilation. But after birth it loses this 
privilege, and with a constitution enfeebled by its taint, is 
compelled to digest its food, and aerate and elaborate its blood 
for itself; hence its speedy exhibition of the hitherto latent 
disease. 

The squamous form of eruption is one of the most frequent 
and decisive external manifestations of the specific virus that 
are observed in the young child ; whereas, squamous affections 
of a non-specific origin are rarely ever met with in the infant. 
If, therefore, circular patches of psoriasis are seen on a child 
within a few months from its birth, there is substantial ground 



448 GONORRHCEA AND SYPHILIS. 

for suspicion that the complaint is venereal. There is a pe- 
culiarity in the anatomical character of the squamae. They are 
thicker, and in many places, as on the head, the face, the but- 
tocks, and about the roots of the nails, are more like thin, lam- 
inated crusts than like the dry, white, furfuraceous, branny 
scales of simple psoriasis, or lepra. Other lesions pointing to 
the same morbific source will also be present. Nevertheless, if 
it be possible for the physician to obtain a truthful medical his- 
tory of the parents, he should bring that to his aid before 
determining upon the case. All the circumstances relating to 
any previous illness of the father or mother, whether before or 
after marriage, should be ascertained and analyzed. They will, 
in all probability, constitute very essential links in the patho- 
logical chain that connects the parental malady with that of the 
offspring, as cause and effect. 

Notwithstanding the utmost diligence to gather the elements 
on which a just diagnosis can be established, a case will some- 
times present itself that will greatly embarrass the shrewdest 
practitioner. The mother, for instance, may never have had 
any venereal trouble. The husband may be able to say the 
same for himself; or he may have had the primary disorder ten 
or fifteen years antecedent to the birth of the child, and may 
never have had constitutional symptoms. Or, instead of the 
husband, an alien may unlawfully have stepped in and contrib- 
uted to the conception of the child. 

Other circumstances relating to the parties, and calculated to 
involve the question of diagnosis in obscurity, are liable to 
transpire ; and the medical man cannot too strongly fortify him- 
self against the many stratagems and other sources of error 
that may beset his path when he is called upon to give his opin- 
ion, either in private or in the halls of justice. 

Treatment. — The administration of mercury directly to the 
infant constitutes the most efficacious treatment for the removal 
of all venereal symptoms which it may exhibit. The idea of 
making the mother or the wet-nurse the medium through which 
to reach the manifestations inherent in the child, has become 
obsolete, and is justly discountenanced every where. 

It matters but little whether the mineral be conveyed into 
the child's system through the cutaneous surface or through 



INFANTILE SYPHILIS. 449 

the stomach ; whether a powder, a liquid, or an ointment be 
used; the ultimate effect on the constitution and on the mal- 
ady will be substantially the same. I have tried all these 
methods with equally favorable results. Either plan, and either 
preparation, as may be most convenient, may be prescribed. 

It is well known that children are rarely affected with that 
factitious disease, salivation, so readily induced in the adult. 
I have never known a child of four or six months to be dis- 
turbed by ptyalism as the result of mercurial action on the 
system. The remarkable power of this class of patients to 
tolerate the presence of mercury without suffering from its 
physiological influence, as usually displayed in the adult, has 
been differently explained. By some writers the immunity of 
the young infant has been attributed to the fact that in the 
latter mercury exerts its force on the skin and intestinal canal, 
and avoids, as it were, the salivary glands. Others consider 
that there is an imperfect development of the organs as regards 
their function in the infant; and I confess that I am inclined to 
accept this theory. So long as the mother's milk constitutes 
the nourishment of the infant, the secretion from its salivary 
glands is not needed. An analogous fact no less curious and 
interesting, and which I cannot forbear to mention in this con- 
nection, is that the function of the maternal mammary glands 
is postponed until the time and occasion arrive when this func- 
tion can be turned to useful account. The lachrymal glands 
furnish still another example of tardy functional activity or 
development. The infant will cry right heartily from the 
moment of its birth, but shed no tears until it is several 
months old. 

The use of the strong mercurial ointment has been in vogue 
for more than half a century for the cure of infantile syphilis, 
and it is the form of medication that has been adopted by a 
large portion of medical practitioners up to the present time. 
Ten or fifteen grains of the ointment should be rubbed upon 
the feet or about the ankles or knees, morning and night, until 
the symptoms begin to yield. It may then be applied with 
less freedom. This is a mild and safe way of introducing the 
mineral into the system. It is no small recommendation to 
state that inunction is preferred by Sir Benjamin C. Brodie to 
any other mode of treatment. His method is this : A drachm 
38* 



450 GONORRHOEA AND SYPHILIS. 

of the ointment is to be spread on one end of a flannel roller, 
which is to be applied round the knee for a period of twenty- 
four or forty-eight hours. If the application create too much 
irritation before the expiration of either of these periods, it 
must be removed for a day or two, and then be resumed. Or 
it may be put first on one knee and then on the other. Mr. 
Brodie is opposed to any other mode of administering mercury 
to the infant. 

There is another region upon which it may sometimes be 
more convenient to apply the ointment than upon the legs or 
thighs, and that is the lateral surfaces of the chest, near the 
axilla, by means of a flannel roller, the portion next the skin 
being covered with the ointment, which should be fresh-made, 
and renewed daily. 

If the remedy in question should produce much irritation on 
the part before it has had time to exert its anti-syphilitic power, 
it should be diluted with rose ointment. 

The liquor of Van Swieten, in the dose of fifteen drops, 
which is equivalent to one sixty-sixth of a grain of deuto- 
chloruret of mercury, is prescribed by Trousseau for infantile 
syphilitic patients. 

A solution of the bichloride of mercury can be given, and be 
continued for ten or twelve weeks, with intermissions of four or 
five days every two or three weeks. If relapse take place, the 
use of the iodide of potassium will be indicated, to the amount 
of two or three grains each day. 

The hydrargyrum cum cretd is a suitable preparation also. 
It should be given in simple syrup. The dose of the powder is 
from half to a whole grain daily. It must be continued for 
five or six weeks after the symptoms have disappeared. Should 
it act too freely on the bowels, the child will need a few drops 
of the camphorated tincture of opium, or a grain or two of 
Dover's powder at night. 

If any ulcers exist on the surface they will do well under a 
dressing consisting of equal parts of simple ointment and the 
nitric oxide of mercury ointment. 

Whatever mercurial preparation be selected, its effect on the 
child should be carefully watched ; and the moment any consti- 
tutional disturbance is displayed the treatment with mercury 
should be suspended, and the cautious use of the iodide of 



INFANTILE SYPHILIS. 451 

potassium be substituted for two or three weeks ; after which 
the mercurial should again be administered. 

Country air and good nourishment will materially aid in the 
restoration and welfare of the child, which should be brought 
up by hand. 

Syphilis and Pregnancy. — The method of treatment to be 
adopted for a female, whether more or less advanced in preg- 
nancy, requires no modification whatever of the remedial course 
that would be appropriate under other circumstances. This 
proposition, or statement, is fully sustained by the experience 
of the best and most reliable observers, with scarcely a dissent- 
ing voice. The opinion was formerly extensively diffused 
among the members of the profession that the administration 
of mercurials was injurious to women during utero-gestation ; 
and also that the class of medicines here referred to had a ten- 
dency to cause abortus, or the death of the foetus. Now, how- 
ever, such prejudices exist only to a very limited extent. They 
have been replaced by views of a directly opposite character. 
The present belief is that, instead of producing an arrest of 
fcetal development and abortion, the use of mercury is calcu- 
lated to prevent these evil consequences. 



FORMULAE OF EEMEDIES. 



FOR GONORRHOEA. 

R. Bals. Copaiba?, | iij. 

Spiritus ./Etheris Nitrici, § ss. 

Tinctura? Kino, § ss. 

Mistura? Camphorse, § ij. 

Morphia? Sulphatis, grs. iij. M. 

Dose. — One teaspoonful three times a day. 

R. Bals. Copaiba?, § iiss. 

Spiritus iEtheris Nitrici, § j. 

Tinctura? Kino, § iss. 

Pulveris Gm. Acacia?, , 3 ij« 

Tincturse Opii, § ss. 

Aqua? Fontana?, § ij. M. 

Dose. — One teaspoonful three times daily. 

R. Pulveris Cubeba?, § vj. 

" Alumina?, 3 vj. M. 

Div. in chart. No. xxiv. 

Dose. — One powder three times a day in a gill of water. 

INJECTIONS IN GONORRHOEA. 

R. Zinci Sulphatis, 

Plumbi Acetatis, aa, gr. xv. 

Tinctura? Catechu, 

Opii, aa, 3j. 

Aqua? Rosarum, § viij- M. 

Injection. — To be used three times daily. 

R. Vini Rubri, S vj. 

Acidi Tannici, grs. xviij. M. 

Injection. — For the male urethra. For the vagina the quantity of tannin 
may be doubled. 

R. Zinci Chloridi, gr- iv. 

Aqua? Fontana?, S vj. M. 

Injection. — To be used two or three times daily. 
(452) 



FORMULAE OF REMEDIES. 453 

ft. Hydrargyri Acidi Nitratis, gtt. ij. 

Aquae Fontanae, § vj. M. 

Injection. — In gonorrhoea or gleet. To be used once, twice, or thrice 
daily. Few patients can tolerate this injection stronger than is here pre- 
cribed. 

ft. Vini Opii 

Liquoris Plumbi Subacetatis, aa, 5 ss. 

Aquae Distillatae, § vj. M. 

Injection. — To be used three times a day, in gonorrhoea or gleet. 

FOR CHORDEE AND PAINFUL ERECTIONS. 

ft. Take spirits of camphor, about thirty drops, every hour, in a wine- 
glass of sweetened milk, until three or four doses are taken, if necessary. 

GLEET. 

ft. Tincturae Ferri Sesquichloridi, § ss. 

Aquae Fontanae, § ij. M. 

Dose. — One teaspoonful thrice daily, in a gill of cold water. 

ft. Copaibae, § ss. 

Tincturae Cantharidis, § ij 

" Ferri Sesquichloridi, S j. M. 

Dose. — Thirty drops thrice daily, in a gill of sweetened water. 

ft. Tincturae Cantharidis, § j 

Quiniae Sulphatis, 3 ss. 

Tincturae Ferri Sesquichloridi, . 3 ij- 

Acidi Sulphurici Diluti, 3 ss. 

Aquae Fontanae, § viij. M. 

Dose. — One ounce three times daily, in an equal quantity of water. 

ft. Morphiae Sulphatis, g r -j- 

Sacchari, ,....' % iij. 

Misturae Camphorae, 

Mucilaginis Acaciae, aa, § ij. 

Olei Terebinthinae, 3 ij- M. 

Dose. — Two drachms thrice daily. Injections the same as in gonorrhoea. 

VEGETATIONS, CONDYLOMATA, AND WARTS. 

WASH. 

ft. Liquoris Sodae Chlorinatae, § ss. 

Aquae Fontanae, § v. M. 

Ft. lotio. 



I 

454 GONORRHCEA AND SYPHILIS. 

FOR WARTS. 

R. Pulveris CEruginis, 

" Sabinae, aa, 3j. M. 

Apply a small quantity every three or four days. 

R. Acidi Chromici, 5 ij. 

Aquae Fontanae, 3 x. M. 

To be applied in the same manner as a strong solution of nitrate of silver, 
once in three or four days. It produces but little pain, and is usually effectual 
in destroying venereal warts. 

R. Zinci Chloridi, 5 ij. 

Aquae Fontana?, 3j« M. 

To be used like the preceding. 

GONORRHCEA IN THE FEMALE. 

R. Copaibae, 

Mucilaginis, 

Pulveris Cubebae, aa, § j. 

Spiritus iEtheris Nitrici, § iss. 

Misturae Camphorae, § viij. M. 

Dose. — A tablespoonful in half a gill of sweetened milk, three or four 
times a day. 

R. Tincturae Lyttee, 

Tincturae Cubebae, aa, § ij. 

Misturae Camphorae, § iv. 

Morphiae Sulphatis, gr. iv. M. 

Dose. — One drachm thrice daily, in half a gill of sweetened milk. 

INJECTIONS. 

R. Tanninae, Bij. 

Potassae Chloratis, 3j- 

Aquae Fontanae, . . § xvj. M. 

Inject an ordinary female syringeful at a time, and repeat the operation ad 

libitum. 

R. Infusionis Cinchonae Rubrae, § x. 

Acidi Nitrici, 3 ss. M. 

To be used as an injection repeatedly during the day. 

R. Tincturae Iodinii Comp., 3ss. 

Aquae Fontanae, § viij. M. 

Inject a syringeful three, four, or five times a day. 



FORMULAE OF REMEDIES. 455 

M. Alumina?, 5j. 

Aqua? Fontana?, Sxij. M. 

Injection. — To be used freely. 

R. Zinci Sulphatis, 

Acidi Tannici, aa, 9j. 

Aqua? Fontana?, S x » M. 

Injection. — To be used freely. 

CHANCRES. 

CAUSTIC APPLICATIONS. — (ABORTIVE TREATMENT.) 

I use the following substances, and give preference to them as they are here 
arranged : — 

1. Concentrated Nitric Acid. 

2. Acid Nitrate of Mercury. 

3. Chloride of Zinc Paste. 

4. Solution of Chromic Acid. 

SLOUGHING CHANCRES, OR ULCERS. 

R. Potassa? Chloratis, § ss. 

Aquae Fontana?, § viij. 

Acidi Hydrochloride gtt. xx. M. 

Signa. — Lotion. To be constantly applied with lint, until healthy action is 
produced, after which a somewhat weaker solution may be employed. Of late 
I have used the chlorate of potash solution to sloughing and atonic ulcers with 
the most gratifying results. 

SINUSES. 

R. Tinctura? Iodinii, §j. 

Inject into the sinus a small quantity every four or five days, if necessary. 

MUCOUS PATCHES ON THE TONGUE. 

M. Extracti Cicuta?, 5 ss. 

Hydrargyri Chloridi Corrosivi, gr. ij. 

Aqua? Fontana?, § vj. M. 

Signa. — Mouth Wash. To be used three or four times daily. 

GARGLES. 

FOR SLOUGHING ULCERS WITHIN THE MOUTH. 

R. Oxymellis ^Eruginis, Sjvel^ij. 

Aqua? Fontana?, § vj. M. 

Signa. — Gargle. To be used three or four times daily. 



456 GONORRHOEA AND SYPHILIS. 

R. Potassae Chloratis, 5 iij- 

Acidi Hydrochlorici, gtt. xx. 

Aquae Fontanae, § viij. M. 

Signa. — Gargle. I know of no gargle or mouth-wash superior to this in 
sloughing ulcerations of the tongue, or elsewhere within the buccal cavity It 
occasions but very little smarting at the time of using it, and may be repeated 
many times in the course of the day. 

R. Acidi Hydrochlorici Diluti, 3 ij. 

Decocti Cinchonae Corticis, § x. M. 

Signa. — Gargle. To be used freely. 

FOR TUBERCLES ON THE FACE. 

R. Pulveris Camphorae, 9j. 

Hydrargyri Oxidi Rubri, . 9ij. 

Unguenti Rosarum, § ij. M. 

A small quantity to be applied at night. In the morning the ointment may 
be removed with soap and water, and the following lotion of acid nitrate of 
mercury immediately applied with a camel's-hair pencil : — 

R. Hydrargyri Pernitratis Liquoris, gtt. xxx. 

Aquae Destillatae, § vj. M. 

Signa. — Lotion. To be applied freely to the tubercles. 

Or, 

R. Hydrargyri Cyanureti, gr. vj. 

Aquae Destillatae, <. . . . S vj. M. 

Signa. — Lotion. 

This lotion should be smeared over the tubercles with a camel's hair pencil, 
once or twice a day. If it produces much smarting, cold water should be used 
freely to subdue it, and the wash should be employed less frequently. It some- 
limes proves efficacious in removing the tubercles from the face without occa- 
sion for any other topical remedy. 



INDEX 



PAGE 



pharynx, 



Abbott, Dr. S. L., secondary syphilis communicated to an infant by 

attendant, . 
Abrasions, superficial, on the tongue, 
Accidents from iodide of potassium, 
Acid, chromic, as an escharotic, 
nitric, as an escharotic, . 

in sloughing phagedena, 
sloughing ulcers, 
danger in applying it to the 
Acid, Nitrate of Mercury as an escharotic, 

Alopecia, 

Amaurosis, syphilitic, 

Ammonia, carbonate, in phagedenic chancre, 

with iodide of potassium, 
Anaesthesia, or deficient cutaneous sensibility, . 
Arseniate of iron in herpes praeputialis, 

and quinine in herpes praeputialis, 
Average time for the healing of indurated chancre, 

between exposure and the appearance of chancre, 
Babington ; method of prescribing mercury, 

Balanitis, 

pseudo 7 

causes of, 

treatment, . 
Baldness, 



an 



Balsam of copaiba, , . 

eruptions produced by, 
useless in vaginal gonorrhoea, 
first employed by Professor Chapman, . 
Behrend, Mr., on potassio-tartrate of iron in primary syphilis, 
Bennett, of Edinburgh, a non-mercurialist, 

on contagiousness of secondary syphilis, . 

cases reported by him, 

Benzoin, compound tincture in sloughing ulcers, . 

Bladder, irritable, 

treatment, . . . 

39 (457) 



. 300 
371 

. 337 
167 

165, 196 
245 

245, 376 
377 

166, 196 
366 
399 
247 
339 
279 
101 
102 
219 
193 
213 

72 

73 

74 

75 

366 

36 

24, 306 

176 

36 

244 

208 

291 

291 

349, 378 

108 

. 110 



458 INDEX. 

PAGE 

Blennorrhagia, 13 

causes of, .... ... 14 

diagnosis, 24 

usual period of latency, 26 

symptoms, 26 

contagion, 28 

treatment of, in the male, 31 

cathartics in, 31 

hot fomentations, 32 

injections of nitrate of silver, 32 

fatal effects of, in, . ... 35 

capules of copaiba, 40 

cubebs, 42 

various injections, ........ 53 

treatment at Chelsea Hospital, 52 

in the female, 158 

diagnosis, . . . . . . 170 

in young female children, 172 

situation of the complaint in the adult female, . . 1 74 

varieties and symptoms, 174 

treatment, 175 

local, 177 

of the uterus, 181 

Blisters in gleet, 64 

Blood in syphilis, 202 

contagion from syphilitic, 287 

Boeck, Professor, on syphilization, 204 

Bones and periosteum, diseases of, . 421 

Boston Society for Medical Improvement, on contagiousness of second- 
ary syphilis, 292 

Bougie, 67 

Bromine and its compounds, 349 

Bubo, 254 

on same side as chancre, 254 

from indurated chancre, rarely suppurates, . . . .217, 255 

true syphilitic, usually indurated, . . . . . . 255 

denotes the system is poisoned, . . . 255 

treatment, 259 

Vidal's opinion, 259 

patient should keep still, 259 

counter-irritants, 260 

Malapert's method of blistering, etc., . . . 260 

method at Paris Hospitals, 260 

« Guy's Hospital, 260 

compression objected to, 262 

fatal results from, .... 262 

indolent or chronic, . . . ' . . . . 262 



INDEX. 459 

PAGE 

Bubo, true syphilitic, sloughing, . . . ... . . 264 

Buchu in blennorrhea, 46 

Buckingham, Dr., anomalous cases, 20 

Busk, Mr., on composition of gummy tubercles, ..... 409 

Calomel to mucous tubercles, 353 

Camphor in painful erections, 57 

Castration in spermatorrhoea, . 138 

Cazenave on contagiousness of secondary syphilis, .... 292 

Cerebral syphilitic affections, 424 

Chancre, indurated, 189, 216 

microscopical examination of, 189 

Hunterian, rarely met with, . . . . . . .189 

never forms on the glans penis, . . . 192 

rarely on os uteri, 191 

period of incubation, 192 

abortive treatment, 193 

views of Dupuytren, 194 

Vidal, . 194 

local applications, ..... 196, 229 

constitutional treatment, 199 

average time for curing indurated, . . . . . 219 

masked or concealed, . . -. 232 

rarely met with, . . . . . . 233 

produces great mutilations, 233 

treatment, 234 

on os uteri, and vagina, 233 

treatment, 235 

inflammatory, . . 237 

how induced, 237 

treatment, 237 

Mr. Key, sarsaparilla and limewater, . . 238 

opium, 238 

phagedenic, 240 

progresses rapidly, 241 

seldom produces constitutional syphilis, . . 242 

treatment, 242 

Chancres, in women, 251 

Chordee, 56, 58 

treatment, 56 

lupulin, 57 

camphor, 57 

Choroiditis, syphilitic, 399 

Circumcision, 78 

citrate of iron, and quinine, 218 

Cod liver oil, as a tonic, 334 

chocolate, and jelly, 334 



PAGE 



460 INDEX. 

Compression of the testis, 91 

Condylomata, 350, 364 

Contagion of secondary syphilis, 286, 292 

Coote, Holmes, on secondary without primary symptoms, . . . 292 
Cubebs in gonorrhoea, 42 

eruptions produced by, 23, 306 

Cullerier, of Paris, on bichloride of mercury, 222 

Davis, Dr. C. A., treatment of blennorrhagia, 52 

Deafness, syphilitic, case of, 375 

Diday, on contagiousness of secondary syphilis, 292 

Discussion at Boston Society for Medical Improvement, . . . 292 

Dura Mater, syphilitic tumors on, 424 

iodide of potassium for, 425 

Eczema praeputialis, 103 

diagnosis of, 104 

treatment of, 105 

Egan, Dr., on the use of mercury, ....... 199, 211 

Emunctory organs, 206 

Epididymitis, 84 

Erections, involuntary and painful, 56 

Ergot in spermatorrhoea, . .135 

Erichsen, Professor, on simple and mercurial treatment, . . . 299 

Eruptions, papular, 310 

diagnosis, 311 

treatment, 314 

squamous, 318, 325 

treatment, 333 

from iodide of potassium, 337 

tubercular, . . 342 

treatment, 345 

pustular, .......... 355 

Erythema syphiliticum, . 306, 441 

Escharotics to chancres, 196 

Excoriations, 113 

Exostosis syphilitic, 431 

Ferruginous remedies and iodide of potassium in the constitutional treat- 
ment of nodes, ... 429 

Fissures, or rhagades, on the tongue, 372 

Fomentations in blennorrhagia, . . . . . . . 32, 178 

Francis, Dr. J. W., on bichloride of mercury, 221 

French Council of Health, statistics of different methods of treating 

syphilis, 208 

Frike, of Hamburgh, a non-mercurialist, . ..... 207 

Fumigations, 316, 400 

Gamberlini, Dr., of Bologna, on iodide of sodium, .... 341 

Gargles, 381 

Gleet, 28,60 



INDEX. 461 

PAGE 

Gleet and matrimony, 29 

microscopical appearances, 62 

treatment, 63 

blisters, 64 

injections, .......... 65 

constitutional treatment, 69 

Gonorrhoea, causes, 14 

diagnosis, 24 

period of latency, 26 

treatment of, in the male, . . . . . . .31 

in the female, ........ 168 

diagnosis, .......... 170 

situation, varieties, and symptoms, .... 174 

treatment, 175 

Grassi, M., analyses of syphilitic blood, 202 

Gummy tubercles, 403 

diagnosis, 404 

cases, . . 404 

give rise to the " horse-shoe," or serpiginous ulcer, 405 

have been found in muscles, .... 407 

in the heart, .... 408 

in tendons, 408 

in the epididymis, . . . 409 

testicle, liver, lungs, brain, etc., .... 409 

their composition, 409 

Hancock on buchu in blennorrhagia, 46 

Hebra and Sigmund, of Vienna, on mercurial inunction, . . . 214 

on communicability of secondary syphilis, 286 

Hemorrhage, urethral, 58 

Hepatic syphilitic affections, 290 

Heredito-syphilitic iritis, . . ' -398 

Herpes prseputialis 96 

symptoms, 96 

treatment, 101 

Hosack, Dr. David, on bichloride of mercury, 221 

Hyoscyamus and camphor in spermatorrhoea, . . . .. .137 

Incubation of the venereal poison, 192 

Infantile syphilis, 432 

Infrequency of indurated chancre, 189 

Injections of nitrate of silver, 32, 178 

objections to those of high power, * . . • 33 

fatal effects from, 35 

in blennorrhagia, ... .... 179 

of balsam copaiba?, 41 

Internal organs syphilitic, 442 

Intoxication, iodic, ......... 338, 363 

Iodine, tincture of, as an injection, .....♦♦ 179 

39* 



462 INDEX. 

PAGE 

Iritis, syphilitic, . 391 

diagnosis, . . . . 393 

treatment, . . * 395 

Iron, arseniate, 99 

citrate of and quinine,. ■* . . .218 

iodide of, 346 

potassio-tartrate, 218, 229, 347, 354 

in phagedenic ulcers, 243 

Irritability of the bladder, 108 

treatment, 110 

Jackson, Dr. James, on lupulin, 135 

Johnson, Dr. James, on sarsaparilla, ....... 226 

Key, Mr., iodide of potassium in sloughing buboes, .... 264 

Larynx, syphilitic, 384 

Lawrence, Mr., of London, on syphilization, 205 

Lee, Mr., of London, trephining in certain eases of syphilitic ostitis, . 428 

Leucorrhoea as a cause of gonorrhoea, 15, 17, 170 

Lichen, varieties, . . . . . 311 

diagnosis, 311 

passes into tubercle, . . . .. . . . .312 

Locher, of Vienna, use of bichloride of mercury, .... 223 

London Lancet, on ............ 223 

Lotion of chlorate of potash, 243, 247 

Lungs, syphilitic, 442 

Lupulin in chordee and erections, ....... 57 

in spermatorrhoea^ . . . 134 

Macula syphilitica, .......... 307 

Marsden, Dr., treatment of secondary eruptions at the Royal Free Hos- 442 

pital, London, 319 

Massachusetts General Hospital, cases of venereal disease arising from 
infantile syphilis, . . .. . ..' . . . . 288 

Menstrual fluid exciting gonorrhoea, . . . . . . 14, 170 

Mercurial fumigations, 316, 400 

Mercurial inunction for curing venereal symptoms, . . . .214 

Mercurial inunction in orchitis, 87 

Mercury, 206 

should be taken on a full stomach, 213 

not useful for sloughing or phagedsenic ulcers, . . . . 210 

bichloride, 221 

one hundred years ago, 223 

a favorite of Dupuytren, 224 

McGrigor, Sir James, reports cases in British army cured without 

mercury, ............ 207 

Methods of treating syphilis, 206 

Miliary tubercles, 426 

Milton, Mr., blisters in gleet, 64 

Mouth and throat, secondary lesions, •. . 370 



INDEX. 463 

page 

Mucous tubercles, . . 350 

treatment, . . . . . . . . . 353 

Myositis, . 407 

Nitrate of silver, injections in blennorrhagia, .... 33, 53 

as a caustic to chancres, 196 

Nitric acid, to sloughing ulcers, . 245, 376 

Nodes, 422 

intra-cranial, .......... 425 

diagnosis, ...-..*... 426 

constitutional treatment, ........ 429 

local treatment, • 430 

Nose, syphilitic diseases of, 386 

treatment, 388 

Nurses, inoculability by syphilitic children, and vice versa, . 286, 291 

Ointment, mercurial, for curing venereal symptoms, .... 214 

Ophthalmia, gonorrhoea^ . 140 

etiology of, ... 142 

from metastasis, 142 

diagnosis, 146 

treatment, 147 

neonatorum, 152 

treatment, . . . . 153 

Opium, in irritability of the system, 238 

Orchitis, . 82 

statistics by Sigmund, 84 

symptoms, 84 

treatment, . .85 

mercurial ointment, 87 

iodide of potassium ointment, ....... 87 

extract of belladonna, 88 

tincture of hyoscyamus, ........ 89 

syphilitic, 416 

belongs to no particular stage of syphilis, . .416 

diagnosis, ........ 418 

pathological appearances, 418 

treatment, . . . , . . . . 418 

Ormerod on iodide of potassium, and mercury, 340 

Os tineas, chancres on, .■ .191 

infrequency of, 191, 236 

Osteocopes, syphilitic, 421 

diagnosis and treatment, 426 

Painful erections, 56 

Pains, tertiary, iodide of potassium in, 429 

urethral, 118 

treatment, 119 

Papillomata, , 166 

treatment, 166 



4G4 . INDEX. 

PAGE 

Papular eruptions, 310 

diagnosis, 311 

treatment, 314 

Paralysis from intra-cranial syphilitic nodes, ..... 425 

Paraphimosis, . . .79 

treatment, 79 

Peaslee, Professor E. R., on nitrate of silver as a caustic, . . . 196 

Penis, bony hardness of, ........ . 56 

Period of latency between primary and secondary symptoms, . . . 267 

longest recorded, 270 

shortest " 270 

Periosteum and bones, syphilitic, ....... 421 

Pharynx, sloughing ulcers, 374 

treatment, 376 

Phymosis, 76 

treatment, . . . . .- 76 

Porte causti que, danger of using, 136 

Potassa fusa as an escharotic, 196 

Potassium, bromide of, in spermatorrhoea, . . . . . .137 

chlorate of, as an injection, 179 

in stomatitis, 230 

strong solution of, as a dressing for sloughing 

ulcers, ■ . . 243, 247 

no standard dose, ' . . . 339 

singular effects of, 337 

in tertiary syphilis, 405, 410 

Potassio tartrate of iron, . 218 

in phagedena, 243 

Pregnancy and syphilis, . 451 

Prepuce, its uses, .......... 72 

Prostitutes, cause of their sterility, .181 

Puncturing the tunica vaginalis testis, and epididymis, ... 90 

Purpura co-existing with rupia, 358 

Pustule plate, 351 

Pustules, syphilitic, .......... 355 

treatment, . ... . . . . 361 

Rectum, syphilitic stricture of, 353 

Reeve, on intra-cranial affections, . 425 

Reid, " " " 424 

Relapses in gonorrhoea, 47 

Rest, its importance in gonorrhoea, 32, 39, 186 

Rheumatism, gonorrheal, 156 

diagnosis, 158 

treatment, . . . . . • • 158 

Rhus glabrum in stomatitis, 230 

Ricord, on experiments without mercury, ...... 208 

Rokitansky, microscopic examination of syphilitic skull, . . . 423 



INDEX. 465 

PAGE 

Roseola syphilitica, 306 

sometimes assumes the annulate form, . . 307 

diagnosis, 308 

treatment, 309 

Royal Free Hospital, London, treatment of secondary eruptions, . .319 

Rupia syphilitica, 356 

two varieties, ....... 358 

treatment, . 361 

iodide of potassium, 363 

Salivation never necessary, 212, 222 

or stomatitis, 229 

chlorate of potash in, 230 

muriatic acid in, . 230 

rhus glabrum in, . . . . . . . . . 230 

Saponaria officinalis, 226 

Sarcocele, 416 

treatment, '418 

Savin and burnt alum as an escharotic, 165 

Scrofula and syphilis, 401 

Secale cornutum in spermatorrhoea, 135 

Secondary syphilis, 266 

symptoms without primary, 281 

Seminal fluid may communicate syphilis, 287 

Sigmund on mercurial inunction, . . . . . . . .214 

on communicability of secondary syphilis, .... 286 

Simpson, Professor, on syphilitic peritonitis, 446 

Sinuses, injections of tincture of iodine for, 265 

Skey, Mr., his method of treating gonorrhoea and gleet, ... 55 

Skull, thickening of, .423 

Smith, Dr. J. L., on syphilis from a nursling to a nurse, . . .291 

Sodium, iodide of, 340 

Speculum uteri, 168 

Spermatorrhoea, .......... 121 

causes, 123 

pathological appearances, . . . . . 128 

treatment, . . . . . . . ... 128 

Squamous eruptions, ......... 325 

Sterility, causes of in prostitutes, . . . . . . . .181 

Syphilis, 187 

secondary, 266 

time between exposure and symptoms, .... 192 

blood in, 202 

hereditary, 432 

infantile, 432 

prognosis, 436 

symptoms, • 437 

infantile diagnosis, 446 



466 INDEX. 

PAGE 

Syphilis, infantile, treatment, . . . . . . . 448 

communicated by vaccination, .... 2S7 

Syphilodermata, 273 

Wilson's nomenclature, 275 

Willan's system, 276 

diagnosis, 276 

color of skin, 276 

insensibility of skin. ...... 279 

cicatrices, 280 

Syphilization, artificial, 208 

diseases from, 205 

Swan Alley sore, 252 

not contagious, 253 

treatment, ........ 252 

Tendons, nodes or gummata in. . 408 

Tertiary pains, • . 427 

syphilis, 401 

in young children, 433 

Testelin on syphilitic hepatic diseases, . 445 

Testicle, swelled, 82 

compression, 91 

best time for, . . ... 92 

Ricord's opinion, 92 

Thymus gland, syphilitic, 446 

Tincture of benzoin comp. for sloughing ulcers, .... 349, 378 

iodine as an injection in vaginal blennorrhagia, . . 179 

Todd, syphilitic diseases of dura mater, 424 

Tongue, syphilitic diseases of, .... 370 

treatment, 375 

swelled in stomatitis, 231 

Transmission of infantile syphilis, ....... 290 

Trousseau on, .... 390 

Travers on sarsaparilla, ......... 226 

Trephining in certain cases of chronic ostitis, . . . . . 428 

Tubercula gummata, 403 

diagnosis, 404 

cases, 404 

produce horse-shoe or serpiginous ulcers, . . 405 

treatment, . 409 

Tubercles, lupoid, 344 

Tubercule muqueux, 351 

Tumors, mucous, 351 

treatment, . 354 

intra-cranial, syphilitic, 424 

Tunica vaginalis, puncturing, 90 

Turenne, M., on artificial syphilization, 203 

Tyrrell, Mr., scarifications in gonorrhoeal ophthalmia, .... 148 



INDEX. 467 

PAGE 

Ulcerations about the toes and the nails, . . . . . . 365 

on the tongue, 370 

sloughing, in the mouth, . . . . . . 374 

Ulcers, serpiginous, . . .341 

phagedenic, 244, 343 

strong acid solution of chlorate of potash, as a 

constant dressing in, 247 

Urethral blennorrhagia in the 1 female, . . ... . . 184 

symptoms and treatment, 185 

hemorrhage, 58 

pains, 118 

Urethral pains, treatment, 119 

Uterus, blennorrhagia of, 181 

treatment, 182 

injections, 183 

Vaccination the medium of communicating syphilis, .... 287 

Vaginitis, chronic, 180 

in young children, ........ 172 

Vegetations, 162 

anatomical structure, 163 

Vidal's opinion of their venereal origin, .... 164 

Acton's, " " " ".'.'".. 164 

treatment, 165 

Velpeau on transmissibility of secondary syphilis, .... 286 

Venereal disease in cats, horses, monkeys, etc., 203 

Veratrum viride in gonorrhoeal rheumatism, 160 

Vidal, on contagiousness of secondary syphilis, 292 

Victor de Meric, interval between primary and consecutive symptoms, 267 

Vienna paste as an escharotic, 196 

Virility unimpaired in orchitis 90 

Waller, produced syphilis with the blood, 287 

Warts, or morbid excrescences, 162 

Weltz, Dr. Robert, on syphilization, •. 203 

Wilks, Mr., on syphilitic liver, 444 

Williams, Dr. H. W., on gonorrhoeal ophthalmia, 144 

Willis, on iodide of potassium, . 340 

Wilson, .Erasmus, on mercury, 211 

Women, chancres in, 251 

pregnant, and syphilis, . , 451 

Zinc, chloride of, as an escharotic, 165, 183 



TESTIMONIALS 

OF PREVIOUS EDITIONS OF THIS WORK. 



" We were a member of the Boylston Prize Committee, which offered the 
question which Dr. Durkee has so ably answered. We heartily commend this 
volume to the profession. We want such works. We want our own men to write 
them. We have relied too much and too long on foreign authors." 

Prof. CHANNING, of Boston. 

From Professor R. D. Mussey, of Cincinnati, Ohio. 

It is gratifying to see, at length, a book on this subject strictly American — 
and still more to see it so well done. The work ought to be in the hands of 
all young practitioners, and it may justly claim a conspicuous place in the 
libraries of the ripened and skilful members of the medical profession. 

From Dr. Thomas C. Brinsmade, late President of the Medical Society of 
the State of New York. 
It is an important and highly useful work. The style is admirable ; and the 
practical character of the volume is clearly shown on every page. I doubt not 
it will be well received by the American Medical Profession generally. The 
plates add greatly to the value of the text. 

From Dixi Crosby, M. D., Professor of Surgery and Obstetrics in Dartmouth 
College. 
I have examined Dr. Durkee's new work on Gonorrhoea and Syphilis, and 3 
sense of professional gratitude impels me to record my unqualified approba- 
tion of it. 

From Dr. Valentine Mott, Professor of Surgery, &c, New York City. 

My Dear Sir : Some little time before you did me the honor to send me a 
copy of your work, I had procured it, and was therefore more or less acquainted 
with its merits. I thank you sincerely for the copy you have sent me, as I shall 
take more interest now in making myself familiar with your views of the in- 
teresting and complicated subject of the Venereal Disease. 

I am gratified to say, that in my opinion you have shown yourself familiar 
with the literature of the subject, and, what is vastly more important for the 
profession of our country, to possess an intimate acquaintance with its prac- 
tical details. Your beautiful volume therefore will, and ought to, become a 
standard work, alike an honor to the country and to yourself. 

Yours truly, V. MOTT. 

Dr. Durkee. 



New Work on Gonorrhoea and Syphilis. — We are gratified to be 
able to announce that a work upon Gonorrhoea and Syphilis, which has been 
long in the process of careful elaboration by its author, Dr. Silas Durkee, of 
this city, is now rapidly passing through the press. We have had the op- 
portunity of perusing the manuscript, and have no hesitation in declaring thut 
the volume will be eminently a useful and practical one. — Boston Medical 
Journal. 

We especially like the critical and discriminating spirit which characterizes 
every part of this work, and its freedom from any servile or sycophantic sub- 
mission to what are called authorities. * * * We have read enough of its 
pages to predict that it will become a standard authority in this department, 
regarding it, as we do, superior to any of the works we have seen on the sub- 
ject, whether foreign or domestic. — American Medical Gazette. 

We have given this work a careful perusal, and feel confident in the asser- 
tion that the medical profession in this country will agree with us in the 
opinion that the author has successfully carried out his design. 

An experience of thirty years in the treatment of skin diseases, as a 
specialty, enables Dr. Durkee to speak with peculiar authority on the diagnosis 
and management of secondary and tertiary Syphilis ; and on this subject, upon 
which general practitioners are most often at fault, the work is particularly 
clear and elaborate. 

We confidently recommend it to the profession as the best work, for a 
manual on these subjects, which has yet been published. — American Medical 
Monthly. 

Dr. Durkee's work on Syphilis is the most complete and practical production 
of the kind in any language. The subject is evidently handled oy a master. — 
College Journal of Medical Science, Cincinnati. 

We are pleased to receive this first full treatise by an American physician as 
well acquainted with the whole subject as Dr. Durkee seems to be. We are 
glad to find in the preface that our author has had such an extended experience 
in the treatment of Venereal Diseases. The book is eminently practical. We 
think that it is bound to have a large sale, and deservedly so.-— Cincinnati 
Lancet and Observer. 

We welcome this volume as being the first comprehensive treatise, as far as 
we remember, on Gonorrhoea and Syphilis which has issued from the American 
press. 

The paramount design of the author has been to furnish a book that shall be 
practically useful, and we feel sure that its objects in this respect will be ful- 
filled. 

The chap f ers on Syphilitic Skin Diseases are made more interesting by 
several well-executed plates. — Charleston (S. C.) Medical Journal. 

P. BLAKISTON, SON & CO., Publishers, 

1012 WALNUT ST., PHILADELPHIA. 



Philadelphia, January 2d, 1882. 

ANNOUNCEMENT. 

The Copartnership heretofore existing between Robert Lindsay and 
Presley Blakiston, under the name of Lindsay & Blakiston, Medical 
Publishers and Booksellers, is this day dissolved, by mutual consent. 

ROBERT LINDSAY. 
PRESLEY BLAKISTON. 

PEESLEY BLAKISTON having purchased from Mr. Robert 
Lindsay all his interest in the late firm, will continue the publication and 
sale of MEDICAL AND SCIENTIFIC BOOKS, At No. 1012 Wal- 
nut Street. 

His son, Kenneth M. Blakiston, and Frank W. Robinson having an 
interest in the business from this date, the name of the firm will be 

P. BLAKISTON, SON & CO. 



MEDICAL, DENTAL, SCIENTIFIC 

AND 

PHARMACEUTICAL BOOKS 

PUBLISHED BY 

P. BLAKISTON, SON & CO., PHILADELPHIA. 



„ Any book in this catalogue can be had from or through booksellers in the principal cities in 
the United States, or will be forwarded free, by mail or express, upon receipt, of the price by the 
publisher. 



AMERICAN HEALTH PRIMERS. . 

Edited by W. W. Keen, m.d. Complete in 12 volumes, handsomely bound in 
cloth. Put up in a neat, strong box. Price #6.00 

Or sold separately, each .50 

I. Hearing and How to Keep It. With illus- 
trations. By Chas. H. Burnett, m.d. 
II. Long Life, and How to Reach It. By J. 
G. Richardson, m.d. 

III. The Summer and Its Diseases. By Jas. 

C. Wilson, m.d. 

IV. Eyesight, and How to Care for It. With 

illustrations. By George C. Harlan m.d. 
V. The Throat and the Voice. With illustra- 
tions. By J. Solis Cohen, m.d. 
VI. The Winter and Its Dangers. By Ham- 
ilton Osgood, m.d. 

" In their practical teachings, learning, and sound 
sense, these volumes are worthy of all the compliments 
they have received. They teach what every man and 
woman should know, and yet what nine-tenths of the 
intelligent class are ignorant oi, or at best, have but a 
smattering knowledge of."— Chicago Inter^Ocean. 



VII. The Mouth and the Teeth. With illustra- 
tions. By J. W. White, m.d., d.d.s. 
VIII. Brain Work and Overwork. By H. C. 
Wood, Jr., m.d. 
IX. Our Homes. With Illustrations. By Henry 

Hartshorne, m.d. 
X. The Skin in Health and Disease. By L. 

D. Bulkley, m.d. 
XL Sea Air and Sea Bathing. By John H. 

Packard, m.d. 
XII. School and Industrial Hygiene. By D. 
L. Lincoln, m.d. 

" These handbooks of practical suggestion deserve 
hearty commendation. They are prepared by men 
whose professional competence is beyond question, and 
for the most part, by those who haye made the subject 
treated the specific study of their lives." — New York 
Sum. 



PRESLE Y BLAKISTON' S 



ACTON, THE REPRODUCTIVE ORGANS. 

The Functions and Disorders of the Reproductive Organs. Their Physio- 
logical, Moral, and Social Relations. By Wm. Acton, m.r.c.s. Fourth Edition. 

Price $2.50 

" In the work now before us, all essential detail upon its subject matter is clearly and scientifically given. We 
recommend it accordingly, as meeting a necessary requisition of the day, refusing to join in that opinion which 
regards the consideration of the topics in question as beyond the duties of the medical practitioner." — The 
London Lancet. 

ADAMS, ON CLUB FOOT. 

Its Causes, Pathology and Treatment. A Revised and Enlarged Edition. 
By William Adams, f.r.c.s. 106 Wood Engravings and six Lithographic 
plates. 8vo. Price $5.00 

" It is a work not only valuable to the specialist, but should be read by every practitioner who has anything to 
do with cases of club foot." — Medical Record. 

AGNEW, ON THE PERINEUM AND FISTULA. 

Lacerations of the Female Perineum and Vesico-vaginal Fistula. Their His- 
tory and Treatment. With many Illustrations. By D. Hayes Agnew, m.d., 
Professor of Surgery, University of Pennsylvania. 8vo. Price $1.50 

So many applications having been made for these papers, as originally issued, 
the author has thought best, after a thorough revision, to place them before the 
profession in book form. 

AITKEN, PRACTICE OF MEDICINE. 

The Science and Practice of Medicine. By William Aitken, m.d., Edin- 
burgh. Third American from Sixth London Edition, greatly enlarged, re- 
modeled and carefully revised; with additions by Meredith Clymer, m.d., 
formerly Professor of Practice, University of New York. With 180 Illustrations 
and large colored map, showing the Geographical Distribution of Disease. 
Large 3 vo. 2 vols. Price, Cloth $ 12.00; Sheep $14.00 



" The author has unquestionably performed a service 
to the profession of the most valuable kind."- The Prac- 
titioner. 



" It would be difficult to point out anything that can- 
not be found in Aitken." — Glasgow Medical Jotirnal. 



"The representative book of Medical science and 
practice." — London Lancet. 

" The additions that have been made ty the Ameri- 
can Editor are copious and important." — American 
Journal Medical Science. 

ALLEN, COMMERCIAL ORGANIC ANALYSIS. 

An Introduction to the Practice of Commercial Organic Analysis. By Alfred 
H. Allen, f.c.s. Vol. 1. Cyanogen Compounds, Alcohols and their Deriva- 
tives, Phenols, Acids, etc. 8vo. Price $3.50 

Vol. H now ready. 8vo. Price $5.00 

Being a treatise on the Properties, Analytical Examination, and Modes of 
Assaying the various Organic Chemicals and Preparations employed in the 
Arts, Manufactures, Medicine, etc. 
ALLAN, FEVER NURSING. 

Notes on Fever Nursing. Addressed to nurses in hospital and private life. 
By James W. Allan, m.d. i2mo. Illustrated. Price .75 

ALLINGHAM, DISEASES OF THE RECTUM. 

Fistula, Haemorrhoids, Painful Ulcer, Stricture, Prolapsus, and other Diseases 
of the Rectum, their Diagnosis and Treatment. By William Allingham, 
f.r.c.s. Fourth Edition, enlarged. 8vo. Price $3.00 

" No book on this special subject can at all approach I " It is, as indeed the verdict of the profession has 

Mr. Allingham's in precision, clearness and practical j already pronounced it, one of the very best works on 

good sense." — London Medical Times and Gazette. \ Disease? of the Rectum." — American Journal of 

I Medical Science. 

ALTHAUS, MEDICAL ELECTRICITY. 

A Treatise on Medical Electricity, Theoretical and Practical, and its Use in 
the Treatment of Paralysis, Neuralgia, and other Diseases, By Julius Althaus, 
m.d. Third Edition, Enlarged. 246 Illustrations. 8vo. Price $6.00 

In revising this new edition the author has carefully brought each section up 
with the latest knowledge of the subject. 



PUB LIC A TIONS. 



ANDERSON, ON ECZEMA. 

The Pathology and Treatment of the various Eczematous Affections or Erup- 
tions of the Skin. By McCall Anderson, m.d. Third Revised and Enlarged 
Edition. 8vo. Price $2.50 

ANSTIE, STIMULANTS AND NARCOTICS. 

With special researches on the Action of Alcohol, Ether and Chloroform on 
the Vital Organism. By Francis E. Anstie, m.d. 8vo. Price $3.00 

" He is an original worker and independent thinker. His opinions and conclusions are valuable, and cannot 
be neglected." — American Medical Journal. 

ATTHILL, DISEASES OF WOMEN. 

Clinical Lectures on Diseases Peculiar to Women. By Lombe At.thill, m.d. 
5th edition, revised and enlarged, with numerous illustrations. i2mo. Cloth. 

Price $2.25 

" It is the concentrated essence of the knowledge of one who has become wise by reason of long and well- 
digested experience in the subjects treated." — American Journal of Medical Science. 

" The work is one of great value to the general practitioner." — American Journal of Obstetrics. 

AVELING, POSTURE IN OPERATIONS. 

The Influence of Posture on Women in Gynecic and other Operations. By 
J. H. Aveling, m.d. Illustrated. 8vo. Price $2.00 

A subject which hitherto has received but little attention is here treated in a 
very thorough manner, showing the importance of certain postures, and the 
various diseases produced by awkward and unhealthy positions. 

BALFOUR, ON THE HEART AND AORTA. 

Clinical Lectures on Diseases of the Heart and Aorta. By G. W. Balfour, 
m.d. Illustrated. 2d Edition. [Preparing. 

"The whole work reflects much credit on its author, and firmly establishes his reputation as an authority on the 
important diseases of which he treats." — London Practitioner. 

BARTH AND ROGER, AUSCULTATION AND PERCUS- 
SION. 

A Manual for the Student. By M. Barth and M. Henri Roger. Trans- 
lated from the 6th French Edition. i2mo. Price $1.00 

BIBLE HYGIENE; 

Or, Health Hints. By a Physician. This book has been written, first, to im- 
part in a popular and condensed form the elements of Hygiene ; second, to show 
how varied and important are the Health Hints contained in the Bible, and third, 
to prove that the secondary tendency of modern Philosophy runs in a parallel 
direction with the primary light of the Bible. i2mo. Price $1. 00 

" The scientific treatment of the subject is quite abreast of the present day, and is so clear and free from unne- 
cessary technicalities that readers of all classes may peruse it with satisfaction and advantage." — Edinburgh 
Medical Journal. 

BIDDLE, MATERIA MEDICA. Eighth Edition. 

Materia Medica for the Use of Students. By John B. Biddle, m.d., Late Pro - 
fessor of Materia Medica at Jefferson Medical College, Philadelphia. 8th 
edition, Revised, Enlarged and Illustrated. 8vo. Price $4.00 

" The additions are valuable, and we must congrat- I " One thing that particularly recommends this work 

ulate the author upon having improved what was j to the student is, that the book is not so large as to dis- 

already so useful a work, both to the student and phy- j courage and cause him to feel that it is impossible for 

sician." — Phila. Medical and Surgical Reporter. him to get over it and so much else in the short time 

" It has been the design of the author to present in ! before him. "—5/. Louis Medical and Surgical Jour- 

his work a text-book for the student. It Is brief, and I nal - 

yet sufficiently comprehensive. His style is clear and | " It contains, in a condensed form, all that is valu- 

yet succinct. He covers the ground — covers it well, able in materia medica, and furnishes the medical 

and cumbers his work with nothing superfluous." — student with a complete manual on this "subject." — 

Atlanta Medical and Surgical Journal. I Canada Lancet. 



PRESLEY BLAKISTON'S 



BLACK, THE REPRODUCTIVE AND RENAL ORGANS. 

The Functional Diseases of the Renal, Urinary and Reproductive Organs, 
with a General View of Urinary Pathology. By D. Campbell Black, m.d., 
f.r.c.S. i2mo. Price $2.00 

"The title of this book sufficiently indicates its character and scope. Some of the chapters are almost ex- 
haustive of their topics. Thus, in the chapter on spermatorrhoea, the whole philosophy and therapeutics 
of this vexatious condition is given with unusual clearness." — Cincinnati Lancet and Observer 

BY SAME AUTHOR. 

DISEASES OF THE KIDNEYS. 

Lectures on Bright's Disease of the Kidneys. Delivered at the Royal Infirmary, 
Glasgow. With 20 illustrations. 8vo. Price $1.50 

BLOXAM. CHEMISTRY,Inorganic and Organic. Fourth Edition. 

With Experiments. By Charles L. Bloxam, Professor of Chemistry in 
King's College, London, and in the Department for Artillery Studies, Wool- 
wich. Fourth edition. With nearly 300 Engravings. 8vo. Price $4.00 

A most complete Text-Book for Schools and Colleges. 

" Professor Bloxam has given us a most excellent and useful practical treatise. His 666 pages (now 700) are 
crowded with facts and experiments, nearly all well chosen, and many quite new, even to scientific men. . . . 
It is astonishing how much information he often conveys in a few paragraphs. We might quote fifty instances of 
this." — Chemical News. 

BLOXAM. LABORATORY TEACHING. Fourth Edition. 

Progressive Exercises in Practical Chemistry. By Charles L. Bloxam, 
Professor of Chemistry in King's College, London, etc. Fourth edition. With 
89 engravings. i2mo. ■ Price $1.75 

This work is intended for use in the Chemical Laboratory, by those who are 
commencing the study of Practical Chemistry. It contains : — 

I. A series of simple Tables for the analysis of unknown substances of all 
kinds. 2. A brief description of all the practically important single substances 
likely to be met with in ordinary analysis. 3. Simple directions and illustra- 
tions relating to Chemical Manipulation. 4. A system of Tables for the detec- 
tion of unknown substances with the aid of the Blowpipe. 5. Short instructions 
upon the purchase and preparation of the tests intended for those who have not 
access to a Laboratory. 

** A great amount of valuable practical information is here condensed into a book of 260 pages, such as only a 
practical teacher could prepare." — New England yournal of Education. 

BRUEN. PHYSICAL DIAGNOSIS. Just Ready. 

A Pocket Book of Physical Diagnosis, for Physicians and Students. By 
Edward T. Bruen, m.d., Asst. Prof, of Clinical Medicine, University of Penn'a. 
Illustrated by Original Wood Engravings. i2mo. Extra Cloth. Price $2.00 

BENNETT. NUTRITION IN HEALTH AND DISEASE. 

A Contribution to Hygiene and Clinical Medicine. By J. Henry Ben- 
nett, m.d. Third Edition, Revised and Enlarged. Cloth. Price $2.50 

BY SAME AUTHOR. 

THE TREATMENT OF PULMONARY CONSUMPTION 
BY HYGIENE, CLIMATE AND MEDICINE. 

With an Appendix on the Sanitaria of the United States, Switzerland and 
the Balearic Islands. Third Edition much Enlarged. Price $2.50 

"Any physician may take it up with every feeling of confidence that the views enunciated by the author will be 
found to be able, honest and orthodox."— Medico- Chirurgical Review. 

BERKART, ASTHMA. 

The Pathology and Treatment of Asthma. By Joseph B. Berkart, m.d. 
8vo. Price $2.50 



PUB LIC A TIONS. 



BEALE ON SLIGHT AILMENTS. 

Slight Ailments, Their Nature and Treatment. By Lionel S. Beale, m.d., 
f.r.s., Professor of Practice, King's Medical College, London. i2mo. Price $1.75 

OUTLINE OF CONTENTS. 
Introductory. The Tongue in Health and Slight Ailments. Appetite. Nausea. Thirst. Hunger. Indigestion, 
its Nature and Treatment. Constipation, its Treatment. Diarrhoea. Vertigo. Giddiness. Biliousness. Sick 
Headache. Neuralgia. Rheumatism. The Feverish and Inflammatory State. Of the Actual Changes in Fever 
and Inflammation. Common Forms of Slight Inflammation, etc., etc. 

. " We venture to say that among the numerous medical publications issued during 1880, there has been none 
which will prove more useful to the young general practitioner, for whom it is really intended, than this volume, 
while the time of the older physician might be much more unprofitably spent." — American "Journal of Medical 
Science. 

BY SAME AUTHOR. 

ON LIFE AND VITAL ACTION IN HEALTH AND DISEASE. 

i2mo. Price $2.00 

THE USE OF THE MICROSCOPE IN PRACTICAL MEDI- 
CINE. 

For Students and Practitioners, with full directions for examining the various 
secretions, etc., in the Microscope. Fourth Edition. 500 Illustrations. Much 
enlarged. 8vo. Price $7.50 



"As a microscopical observer, and a histological 
manipulator, his (Dr. Beale) skill and eminence are 
generally conceded." — Popular Science Monthly. 



" We have before us Prof. Beale's work, The Micro- 
scope in Medicine, a book which it gives us pleasure to 
recommend to every student of microscopy, whether he 
be a physician or naturalist." — "Journal of the Frank- 
lin Institute, Philadelphia. 

HOW TO WORK WITH THE MICROSCOPE. 

A Complete Manual of Microscopical Manipulation, containing a full descrip- 
tion of many new processes of investigation, with directions for examining ob- 
jects under the highest powers, and for taking photographs of microscopic 
objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. 
Octavo. Price $7.50 

"The Encyclopaedic character of this last edition of Dr. Beale's well known work on the Microscope renders 
It impossible to present an abstract of its contents ; suffice it to say, that anything in his department upon which 
the physican can desire such information will be found here, and much more in addition. It is, moreover, a store- 
house of facts, most valuable to the physician, and is indispensable to every one who uses the microscope." — 
American Journal of Medical Science. 

BIOPLASM. 

A Contribution to the Physiology of Life, or an Introduction to the Study of 
Physiology and Medicine, for Students. With numerous Illustrations. 

Price $2.25 
PROTOPLASM; or MATTER AND LIFE. 

Third Edition, very much enlarged. Nearly 350 pages. Sixteen Colored 
Plates. Part 1. Dissentient. Part 11. Demonstrative. Part in. Suggestive. 
One volume. Price $3.00 

LIFE THEORIES ; Their Influence upon Religious Thought. 

Six Colored Plates. Price $2.00 

ONE HUNDRED URINARY DEPOSITS, 

On two sheets, for the Hospital, Laboratory, or Surgery. Each Sheet $1.00, or 
on Rollers, Price $1.25 

BERNAY, CHEMISTRY. 

Notes for Students in Chemistry. Compiled from Fowne's and other manuals. 
By Albert J. Bernay, ph.d. Sixth Edition. i2mo. Price $1.25 

BOCK, ANATOMY. 

An Atlas of Human Anatomy. By Prof. C. E. Bock, of Berlin. Thirty-seven 
Colored Plates, containing about 200 figures. Quarto. Half Roan. Price $15.00 

This is one of if not the best Anatomical Atlas now to be had, and its produc- 
tion in Germany makes it certainly the cheapest. 



PRESLEY BLAKISTON* S 



BEASLEY. THE BOOK OF PRESCRIPTIONS. 

Containing over 3100 Prescriptions, collected from the Practice of the most 
Eminent Physicians and Surgeons — English, French and American ; a Com- 
pendious History of the Materia Medica, Lists of the Doses of all Officinal and 
Established Preparations, and an Index of Diseases and their Remedies. By 
Henry Beasley. Fifth Edition, Revised and Enlarged. Price $2.25 

BY SAME AUTHOR. 

THE DRUGGIST'S GENERAL RECEIPT-BOOK. 

Comprising a copious Veterinary Formulary; numerous Recipes in Patent 
and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and Cos- 
metics; Beverages, Dietetic Articles and Condiments; Trade Chemicals, Scien- 
tific Processes, and an Appendix of Useful Tables. Eighth Edition. Price $2.25 

THE POCKET FORMULARY and Synopsis of the British and 
Foreign Pharmacopoeias. 

Comprising Standard and Approved Formulae for the Preparations and Com- 
pounds Employed in Medical Practice. Tenth Edition. 511 pp. i8mo. 

Price $2.2$ 
BENTLEY AND TRIMEN'S MEDICINAL PLANTS. 

A New Illustrated Work, containing full botanical descriptions, with an account 
of the properties and uses of the principal plants employed in medicine, especial 
attention being paid to those which are officinal in the British and United States 
Pharmacopoeias. The plants which supply food and substances required by the 
sick and convalescent are also included. By R. Bentley, f.r.s., Professor of 
Botany, King's College, London, and H. Trimen, m.b., f.h.s., Department of 
Botany, British Museum. Each species illustrated by a colored plate drawn 
from nature. In Forty-two parts. Eight colored plates in each part. 

Price $2 each, or handsomely bound in 4 volumes, Half Morocco, $90.00 

" It would be impossible to enumerate all tbe new 
plants that are here delineated. The result is a work 
which, from all points ofview,isa credit to the scientific 
literature of the day." — London Lancet. 

"It is an indispensable work of reference to every one 



" This work may be recommended as a most useful 
one to druggists, and all who desire to be familiar 
with the Botany of Medicinal Plants." — Druggists' 
Circular. 

" The work when complete (it is now complete) 
will be the most valuable compend of Medical Botany 
ever published." — Boston Journal of Chemistry. 



interested in pharmaceutical Botany." — London Phar 
rnaceutical Journal. 

BRADLEY, ANATOMY. 

Comparative Anatomy and Physiology. By S. M. Bradley, f.r.c.s. Sixty 
Illustrations. Third Edition. Price $2.00 

BRUNTON, ACTION OF MEDICINES. 

Experimental Investigation of the Action of Medicines. Part I, Circulation. 
By T. Lauder Brunton, m.d., f.r.s. Second Edition. {Preparing. 

BYFORD. DISEASES OF WOMEN. New Revised Edition. 

The Practice of Medicine and Surgery, as applied to the Diseases of Women. 
By W. H. Byford, a.m., m.d., Professor of Obstetrics and The Diseases of Wo- 
men and Children, in the Chicago Medical College. Third Edition. Revised 
and Enlaged, much of it rewritten, with numerous additional illustrations. 

Price, in Cloth $5.00 ; Leather, $6.00 

"The treatise is as complete a one as the present "The author is an experienced writer, an able teach- 

state of our science will admit of being written. We j er in his department, and has embodied in the present 

commend it to the diligent study of every practitioner work the results of a wide field of practical observa- 

and student, as a work calculated to inculcate sound ' tion. We have not had time to read its pages critically, 

principles and lead to enlightened practice. — New j but freely commend it to all our readers, as one of the 

York Medical Record. \ most valuable practical works issued from the Ameri- 

i can press." — Chicago Medical Examiner. 

BY SAME AUTHOR. 

ON THE UTERUS. The Chronic Inflammation and Displace- 
ment of the Unimpregnated Uterus. 

An Enlarged Edition, with Illustrations. 8vo. Price #2.50 

"A good book from a good man." — American Journal Medical Science. 

" It is,- a sensible, practical work, and cannot fail to be read with interest and profit." — Boston M.dical and 
Surgical Journal. 



PUB LIC A TIONS. 



BRAUNE, TOPOGRAPHICAL ANATOMY. 

An Atlas of Topographical Anatomy. Thirty-four Full-page Plates, Photo- 
graphed on Stone, from Plane Sections of Frozen Bodies, with many other illus- 
trations. By Wilhelm Braune, Professor of Anatomy at Leipzig. Translated 
and Edited by Edward Bellamy, f.r.c.s., Lecturer on Anatomy, Charing 
Cross Hospital, London. Quarto. Price, Cloth, $10.00; Half Morocco, $12.00 

"As a whole the work cannot fail to meet with a hearty reception by every progressive student of the human 
body. To the surgeon it is a contribution to the study of topographical anatomy which needs to be known to be 
properly appreciaied To such practitioners who reside in large cities, where anatomy can be studied upon the 
cadaver, it will afford a valuable aid, while to those who are without such means of study it is an almost indis- 
pensable addition to a working library." — New York Medical Record. 

" We commend the book most heartily to the Profession." — American Journal of Medical Science. 

BUCKNILL AND TUKE ON INSANITY. 

A Manual of Pyschological Medicine : containing the Lunacy Laws, the 
Nosology, CEtioiogy, Statistics, Description, Diagnosis, Pathology (including 
morbid Histology), and Treatment of Insanity. By John Charles Bucknill, 
m.d., f.r.s., and Daniel Hack Tuke, m.d., f.r.c.p. Fourth Edition, much 
enlarged, with twelve lithographic plates, and numerous illustrations. Octavo. 

Price $8.00 

" We have read no book in any language, and certainly none in English, which ought to be preferred to this 
for a text book, by those who wish to make a thorough study of the subject. — Edinburgh Medical Journal. 
" We can heartily commend the work. — American Journal of Insanity. 

BURDETT, HOSPITALS. 

Pay Hospitals and Paying Wards throughout the World. Facts in support 
of a rearrangement of the system of Medical Relief. By Henry C Burdett. 
8vo. . Price $2.25 

" Mr. Burdett displays and discusses the whole scheme of Hospital accommodation with a comprehensive 
understanding of its nature and extent. — American Practitioner. 

BY SAME AUTHOR. 

COTTAGE HOSPITALS. 

General, Fever, and Convalescent : their Progress, Management, and Work. 
Second Edition, rewritten and much Enlarged, with many Plans and Illustra- 
tions. Crown 8vo. Price $4.50 

Contents. — Chap. — 1. Origin and Growth of the Cottage Hospital System. 2. Comparative Success of 
Treatment in large and small Hospitals. 3. Finance. 4. Cottage Hospital Construction and Sanitary Arrange- 
ments. 5. The Medical and Nursing Departments. 6. Domestic Supervision and General Management. 7. 
Cottage Hospital Appliances and Fittings. 8. Cottage Fever Hospitals . 9. Midwifery in Cottage Hospitals. 10. 
Remunerative Paying Patients. 11. Convalescent Cottages . 12. Cottage Hospitals in America. 13. Mortu- 
aries. 14. A more Detailed Account of certain Cottage Hospitals, with Plans and Elevations. 15. Selected and 
Model Plans criticised and compared, with a detailed description of various Hospitals. 16. Peculiarities and 
Special Features in the Working of Cottage Hospitals. With an Appendix containing much statistical and useful 
information. 

" Mr. Burdett's book contains a mass of information, statistical, financial, architectural, and hygienic, which has 
already proved of great practical utility to those interested in cottage hospitals, and we can confidently recom- 
mend this second edition to all who are in search of the kind of information which it contains." — Lancet. 

BUZZARD, SYPHILITIC NERVOUS AFFECTIONS. 

Clinical Aspects of Syphilitic Nervous Affections. By Thos. Buzzard, m.d. 
121110. Price $1.75 

CARPENTER, THE MICROSCOPE. Sixth Edition. 

The Microscope and its Revelations. By W. B. Carpenter, m.d., f.r.s. 
Sixth Edition. Revised and Enlarged, with over 500 Illustrations. Price $5.50 



" Not only the student of medicine, but amateurs, 
and others interested in the study of natural history, 
will find this volume one of great practical value." — 
Nw York Medical Journal. 

" It is by far the most < complete and useful treatise 
now accessible to the stu!lent." — The Technologist. 



"As a text book of Microscopy in its special relation 
to natural history and general science, the work before 
us stands confessedly first, and is alone sufficient to 
supply the wants of the ordinary student." — American 
Journal of Microscopy. 



io PRESLE V BLAKISTONS 

Cazeaux's Great Work on Obstetrics. 

THE MOST COMPLETE TEXT-BOOK NOW PUBLISHED. 
GREATLY ENLARGED AND IMPROVED. 

CONTAINING 175 ILLUSTRATIONS. 

A Theoretical and Practical Treatise on Midwifery, including the Disease* 
of Pregnancy and Parturition, by P. Cazeaux, Member of the Imperial 
Academy of Medicine ; Adjunct Professor in the Faculty of Medicine of 
Paris , etc., etc. Revised and Annotated by S. Tarnier, Adjunct Pro- 
fessor in the Faculty of Medicine of Paris ; Former Clinical Chief of the 
Lying-in-Hospital, etc., etc. Sixth American from the Seventh French Edv 
tion. Translated by Wm. R. Bullock, M. D. In one volume Royal Oc 
tavo, of over 1100 pages, with numerous Lithographic and other Illustra 
tions on Wood. 

Price, bound in Cloth, bevelled boards, . . . $6.00 
" " Leather, . 7.00 

M. Cazeaux's Great Work on Obstetrics has become classical in its character, and 
almost an Encyclopaedia in its fulness. Written expressly for the use of students of 
medicine, and those of midwifery especially, its teachings are plain and explicit, present- 
ing a condensed summary of the leading principles established by the masters of the 
obstetric art, and such clear, practical directions for the management of the pregnant, 
parturient, and puerperal states, as have been sanctioned by the most authoritative 
practitioners, and confirmed by the author's own experience. Collecting his materials 
from the writings of the entire body of antecedent writers, carefully testing their correct- 
ness and value by his own daily experience, and rejecting all such as were falsified by 
the numerous cases brought under his own immediate observation, he has formed out of 
them a body of doctrine, and a system of practical rules, which he illustrates and enforces 
in the clearest and most simple manner possible. 

OPINIONS OF THE PRESS. 

" It is unquestionably a work of the highest excellence, rich in information, and perhaps fuller in details 
than any text-book with which we are acquainted. The author has not merely treated of every ques- 
tion which relates to the business of parturition, but he has done so with judgment and ability." 
British and Foreign Medico- Chirurgical Review. 

" The translation of Dr. Bullock is remarkably well done. We can recommend this work to those 
especially interested in the subjects treated, and can especially recommend the American edition." 
Medical Times and Gazette. 

" The edition before us is one of unquestionable excellence. Every portion of it has undergone a 
thorough revision, and no little modification ; while copious and important additions have been made to 
nearly every part of it. It is well and beautifully illustrated by numerous wood and lithographic 
engravings, and, in typographical execution, will bear a favorable comparison with other works of the 
same class." — American Medical Journal. 

" In the multitudinous collection of works devoted to the propagation of human beings, and to t-ht 
details of parturition, none, in our estimation, bears any comparison to the work of Cazeaux, in it» 
entire perfectness ; and if we were called upon to rely alone on one work on accouchments, our choice 
woulJ fall upon the book before us without any kind of hesitation." — West. Jour, of Med. and Surgery 

" We do not hesitate to say, that it is now the most complete and best treatise on the subject in th* 
Bnglish language." — Buffalo Medical Journal. 

"We know of no work on this all-important branch of our profession that we can recommend to th* 
nudent or practitioner as a safe guide before this." — Chicago Medical Journal. 



PUBLICA TIONS. 



CHARTERIS, PRACTICE OF MEDICINE. 

Hand-Book of the Practice of Medicine. By M. Charteris, m.d., Member 
of Hospital Staff and Professor in University of Glasgow. With Microscopic and 
other illustrations. Price $2.00 

" We have not often met with a book which can be so confidently recommended to physicians or men in general 
practice. " — Lancet. 

" The style in which it is written is clear and at-traetive. The illustrations are a marked feature in it. It can 
be recommended as a very reliable, handy book, well adapted for ready reference." — Neiv Remedies. 

CHAVASSE ON CHILDREN. 

The Mental Culture and Training of Children. By Pye Henry Chavasse. 

i2mo. Price $1.00 

The mental culture and training of children is of immense importance. Many 

children are so wretchedly trained, or rather not trained at all, and so mismanaged, 

that a few thoughts on this subject cannot be thrown away, even upon the most 

careful. 

CLAY ON OBSTETRIC SURGERY. Third Edition. 

A complete Hand-Book of Obstetric Surgery, with Rules for every Emergency 
and Descriptions of the more difficult as well as the every day operations. By 
Charles Clay, m.d., with numerous illustrations. From the Third London Edi- 
tion. i2mo. Price $2.00 

" It is a useful and convenient book of reference ; the illustrations are good, and the book will be found of value 
to the student and young practitioner, as well as to the skilled Obstetrician." — American Journal of Obstetrics. 

CLEVELAND, POCKET DICTIONARY. 

A Pronouncing Medical Lexicon, containing correct Pronunciation and Defi- 
nition of terms used in medicine and the collateral sciences. By C. H. Cleve- 
land, m.d. Twenty-sixth Edition. i6mo. 

Price, Cloth, 75 cents ; Tucks with Pocket, $1.00 
This is a most convenient size for the pocket, and contains all the principal words 
in use,. together with rules for pronunciation, abbreviations used in prescriptions, list 
of poisons, their antidotes, etc. 

COHEN, INHALATION. Enlarged Edition. 

Inhalation, its Therapeutics and Practice, including a Description of the Ap- 
paratus Employed, etc. By J. Solis Cohen, m.d. With cases and Illustrations. 
A New Enlarged Edition. 8vo. Price $2.50 

" The book has the merit of containing much information that cannot be found elsewhere." — N. Y. Medical 
Journal. 
" One of the best treatises we have seen on this subject." — Medical Times and Gazette. 

BY SAME AUTHOR. 

CROUP, 

In its Relation to Tracheotomy. 8vo. Price $1.00 

CLARKE, SURGERY. 

Outlines of Surgery and Surgical Pathology, including the Diagnosis anrl 
Treatment of Obscure and Urgent Cases. By F. LeGross Clarke, f.r.s. 
Second Edition. 8vo. Price $2.00 

COBBOLD, PARASITES. 

A Treatise on the Entozoa of Man and Animals, including some account of 
the Ectozoa. By T. Spencer Cobbold, m.d., f.r.s. With 85 illustrations. 
8vo. Price I5.00 



12 



PRESLE Y BLAKISTON'S 



DAY ON CHILDREN. 

A SECOND EDITION. JUST READY. 

The Diseases of Children. A Practical and Systematic Treatise, for Practitioners 
and Students. By Wm. Henry Day, m.d. Second Edition. Enlarged. 8vo. 
752 pp. Price, Cloth, $5.00 ; Sheep, $6.<r 

What Prominent Professors Say of It. 



"The more I read Dr. Day's book, the more I like 
it. I shall recommend it to the students of George- 
town College." — Prof. J. Taber Johnson, Washington, 
D.C. 

" I pronounce the book a good one, and one tha* 
promises to be useful to both practitioners and stu- 
dents." — Prof. W. A. Edmunds, St. Louis. 

<l I think it admirably adapted to the uses of practi- 
tioners and students of medicine." — Prof. Hannah T. 
Choasdale, Woman's Medical College, Philadelphia. 

" Believing the work well adapted to meet the wants 
of the student as well as the practitioner, it will give 
me pleasure to recommend it to the classes of Rush 
Medical College." — Prof. De Lf.sk.ie Miller, Chicago. 

"It is the work for which we have so long felt the 
want and need. I take pleasure in recommending it." 
— Prof. C. T. Bedford, Indianapolis, Ind. 

" The practitioner can confidently rely upon finding 
in its pages the very best and latest knowledge con- 



cerning the diseases of children." — Prof. W. J. Conv 
lin, Dayton, 0. 

" It is just what a student and a busy practitioner 
needs. I can heartily recommend it."— Prof. J. M. 
Dunham, Columbus, 0. 

" It is, in my judgment, the most satisfactorily ar- 
ranged and eminently practical work upon the ail- 
ments of infancy and childhood yet published in the 
English language." — Prof. F. L. Sim, Memphis, Term. 

" It is especially to be recommended for judicious 
comments on infant feeding, etc." — Prof. H. G. Lan- 
dis, Columbus, O. 

" An excellent practical treatise, superior to any of 
the reprints in the department of Diseases of Children 
that I have seen." — Prof. E. 0. F. Roler, Chicago. 

" It is fairly entitled to the highest rank among the 
text-books on Diseases of Children."— Prof. J.B. Kings- 
ley, St. Louis. 



PRESS OPINIONS. 



"A careful examination of this book leads us to 
characterize it as a plain, straightforward treatise on 
the subject upon which it treats, .... giving 
sound practical advice." — Philadelphia Medical Times. 

"We heartily recommend this book to tko profession 
as a safe and reliable guide in the department of which 
it treats." — Medical and Surgical Reporter. 

"The book is wonderfully readable." — British Medi- 
cal Journal. 

" The article on the true diseases of children, those 
of the pulmonary, circulatory and renal apparatus, and 
the nervous system, are in many parts exhaustive. . 
. . The writing is clear and forcible, and to the 
point."^-.4menccai Journal of Medical Sciences. 

"We have no doubt it will bo read with i iterest, 
which its style, as well as its matter, deserves." — Lub- 
lin Medical Journal. 

" Taking the book as a whole, its correct classifica- 
tion, its perfect style, and its comprehensiveness place 
it in advance of all other books upon tho same sub- 
ject." — Walsh's Retrospect. 

" A safe guide for the etudent and practitioner." — 
College and Clinical Reoord. 

" One ef the most useful and valuable additions to 
the medical literature of the present day. No medical 
l'brary should be without this book on its shelves." — 
Medical Bulletin. 

"Dr. Day brings to his task a large experience, and 
evidences a very thorough knowledge of the litera- 
ture, native and foreign, pertaining to this special 
branch of medicine. The book has been written with 
great care, and the author is a good writer. The pub- 
lisher's part of the task has also been excellently per- 
formed." — Boston Medical and Surgical Journal. 

"We advise every physician to have a copy." — 
Braithwaite > 8 Quarterly Epitome. 



11 Altogether we can heartily commend this volume 
to any students of this subject that desire to obtain the 
latest and most judicious compend of our knowledge 
of Children's Diseases." — Detroit Lancet. 

" One of the most satisfactory guides in the diagnosis 
and treatment of diseases peculiar to children to be had 
in the language." — New Remedies. 

" This volume, from the title-page to the end of the 
last chapter, abounds in just such practical and well- 
put information as every man, in the course of his 
treatment of children's diseases, must oftentimes feel 
the need." — Medical Herald, Louismlle. 

" We commend it particularly for its practical worth, 
beim; full of valuable hints in regard to diagnosis and 
treatment." — Medical Annals, Albany, N. Y. 

" It should be in the library of every medical stu- 
dent and practitioner." — Southern Medical Record. 

" It is full of valuable facts and suggestions that will 
make a welcome addition to the working library of 
every practitioner." — Ohio Medical Journal. 

"Plain, full and eminently practical." — Southern 
Clinic. 

" The book is up to the times, and we cordially com- 
mend it to those for whom it is written, but especial- 
ly the student." — Therapeutic Gazette. 

" A safe guide in practice." — Pacific Medical and Sur- 
gical Journal. 

"It is not too much to say of it that it is probably 
not equaled, and certainly not excelled, by any other 
book on its subject." — Michigan Medical News. 

" A thoroughly practical work." — Independent Prac- 
titioner. 

" It is just such a book as is wanted by the general 
practitioner." — Medical Brief. 



Price : Cloth, $5.00 ; Leather, $6.00. For sale by all booksellers, 
or sent to any address, postpaid, on receipt of price. 



PUBLICATIONS. 13 



COULSON, THE BLADDER. Sixth Edition. 

Diseases of the Bladder and Prostate Gland. By Walter J. Coulson, f.r.c.s. 
Sixth Edition. Revised and Enlarged, with 22 Engravings. 8vo. Price $6.40 

CRIPPS, THE RECTUM. 

Cancer of the Rectum. Its Pathology, Diagnosis and Treatment. By. W. 
Harrison Cripps, f.r.c.s. Illustrated by Plates. 8vo. Price $2.40 

CORMACK. CLINICAL STUDIES. 

Illustrated by Cases Observed in Hospital and Private Practice. By Sir 
John Rose Cormack, m.d., k.b., etc. Illustrated. 2 vols. 1127 pp. Price $5.00 

Contents. — Vol. i. — Chapter i. Relapsing Fever. 11. Cholera, in. Scarlatinous Nephritis, iv. Puerperal 
Convulsions, v. Glandular Degeneration of the Kidney, and Its Relation to Scrofula, vi. Infantile Remittent 
Fever, vn. Labor Complicated with Cauliflower Excrescence of the Uterus, vm. Value of the Dark Abdominal 
Line as a Test of Recent Delivery, ix. Dystocia from Cystous Kidney in the Mature Foetus, x. Hernia of the 
Uterus. 

Vol. 11.— Chapter I. Air in the Organs of Circulation, n. Reflex Convulsions in Infancy, in. Pharyngo- 
Laryngo-Tracheal Diphtheria, iv. Diphtheria, v. Paralytic Affections, vi. Paralytic Affections in Enteric 
Fever. VII. Treatment of Paralytic Affections, vm. Non- Venereal Discharges from the Urethra, ix. Scarla- 
tinal Vaginitis, x. Congenital Syphilis, xi. Chronic Poisoning by Chloroform, xn. Resection of the Shoulder 
Joint, xiii. Concussion of the Brain, xiv. General Paralysis with Insanity, xv. Short Attacks of Insanity. 

DAY ON HEADACHES. 

The Nature, Causes, and Treatment of Headaches. Third Edition. Illus- 
trated. By Wm. Henry Day, m.d. Price $2.00 

Summary of Contents. — Headache from Cerebral Anaemia, Cerebral Hypersemia, Sympathetic, Congestive, 
Dyspeptic or Bilious Headaches, Headache from Plethora, from Exhaustion, from Change in Cerebral Tissue, 
from Affections of the Periosteum, Nervous and Nervo-Hyperaemic Headache, Toxaemic, Rheumatic, Arthritic 
or Gouty Headache, Neuralgic Headache, and Headaches of Childhood, Early and Advanced Life. 

" Well worth reading. The remarks on treatment are very sensible." — Boston Medical and Surg, yournal. 

DALBY, ON THE EAR. 

The Diseases and Injuries of the Ear. By W. B. Dalby, m.d., Surgeon and 
Lecturer on Aural Surgery, St. George's Hospital. With Illustrations. i2mo. 

Price $1.50 



'A safe and readable introduction to aural surgery." 
Medical Press and Circular, 

" Dr. Dalby has presented us with a very readable 
little book, which is destined to render much service in 
the saving of ears." — N. Y. Medical Journal. 



"The lectures occupy 226 pages, are clearly and 
consisely written, contain a number of good illustrations, 
and are well worth the careful study of both student 
and practitioner. To aurists the work will be most 
welcome and valuable." — Specialist. 



DILLINGBERGER, WOMEN AND CHILDREN'S DIS- 
EASES. 

A Hand-Book of the Treatment of the Diseases Peculiar to Women and Chil- 
dren. By Dr. Emil Dillingberger. i2mo. Price $1.50 

" It is a magnum in parvo. The style is simple, clear, lucid, and free from theoretical discussion. No one will 
regret the small outlay for this volume. — Richmond, and Louisville Medical Journal. 

DUNGLISON, THE PHYSICIAN'S REFERENCE BOOK. 

The Practitioner's Reference Book, containing Therapeutical and Practical 
Hints, Dietetic Rules, and General Information. By Richard J. Dunglison, 
m.d. Second Edition. 8vo. Price $3.^0 

" The demand for a second edition so soon after the 



" We can heartily commend this book as one that 
must prove very useful to the general practitioner." — 
The Medical Record. 



publication of the first volume shows that this work is 
appreciated by the profession." — Canada Lancet. 



DURKEE, VENEREAL DISEASES. Sixth Edition. 

Gonorrhoea and Syphilis. By Silas Durkee, m.d. Sixth Edition. Revised 
and Enlarged, with Portrait and Eight Colored Illustrations. 8vo. Price $3.50 

" We may, finally, recommend Dr. Durkee's book as eminently practical, well written, full of excellent counsel, 
and worthy of being cons ilted by every member of the profession. A late number of the London Medical Times 
and Gazette also speaks of the book in terms of the highest approval. "-^Boston Medical and Surgical Journal. 



14 PRESLEY BLAKISTON'S 

DAGUENET, OPHTHALMOSCOPY. 

A Manual of Ophthalmoscopy, for the Use of Students. By Dr. Dagurnet. 
Translated from the French, by Dr. C. S. Jeaffreson, f.r.c.s.e. Illustrated. 
i2mo. Price $1.50 

"Its portable size, the condensed nature of its text, and the admirably systematic arrangement of its contents, 
render it extremely useful as a pocket manual for Students. — Translator' s Preface. 

DOBELL, WINTER COUGH AND CATARRH. 

On Winter Cough, Catarrh, Bronchitis, Emphysema, Asthma, etc. By 
Horace Dobell, m.d., Lecturer at the Royal Hospital for Diseases of the 
Chest, Third Edition. With Colored Plates. 8vo. Price $3. 50 

BY SAME AUTHOR. 

ON LOSS OF WEIGHT. Revised Edition. 

Blood Spitting and Lung Disease. Colored Frontispiece of Lung. Tabular 
Map, etc. Second Edition Enlarged. 8vo. Price $4.00 

DOMVILLE, ON NURSING. 

A Manual for Hospital Nurses and others engaged in attending to the sick. 
4th Edition. With Recipes for Sick Room Cookery, etc. Price $1.00 

DRUITT'S MODERN SURGERY. Eleventh Edition. 

The Surgeon's Vade Mecum ; a Manual of Modern Surgery. By Robert 
Druitt, f.r.c.S. Eleventh Enlarged Edition, with 369 Illustrations. 864 pp. 
1878. Price #5.00 

This is a most complete, accurate, and trustworthy Hand, or Text-Book of Sur- 
gery. Unrivaled as a book for the Student. Fully illustrated, and brought up to 
the present state of the science. In use in many Medical Colleges. 

DULLES, ACCIDENTS. 

What to do First, in Accidents and Poisoning. By C. W. Dulles, m.d. Il- 
lustrated. i6mo. Price .50 

So plain and sensible that it ought to be introduced 



" Its usefulness entitles it to a wide and permanent 
circulation." — Boston Gazette. 

" A complete guide for sudden emergencies. — Phila- 
delphia Ledger. 



into every female seminary. — Evening Chronicle, 
Pittsburgh. 



EDWARDS, BRIGHT'S DISEASE. New Edition. 

How a Person Affected with Bright* s Disease Ought to Live. By Jos. F. Ed- 
wards, m.d. Second Edition. i2mo. Price .75 

BY SAME AUTHOR. 

DYSPEPSIA. Just Ready. 

How to Avoid It. i2mo. .75 

Contents. — Chap. i. — Food. 11. Digestion, in. How to Cook Food. iv. How and What We Ought to Eat. 

CONSTIPATION. New Edition. 

Plainly Treated and Relieved Without the Use of Drugs. Second Edition. 
• i2mo. Price .75 

MALARIA. 

Malaria : What It Means ; How to Escape It ; Its Symptoms ; When and 
Where to Look for It. i2mo. Price .75 

These are invaluable little treatises upon subjects that enter painfully into the 
life experiences of a large majority of the human family. Dr. Edwards shows not 
only how they may be avoided, but in plain and simple language he tells those 
already afflicted with them how they may find relief. Many learned works have been 
written upon their treament; but the authors have, in nearly every case, neglected 
to show to the public how to avoid them. 



PUB LIC A TIONS. 



*5 



EKIN, WATER ANALYSIS. 

Potable Water. How to Form a Judgment on the Suitableness of Water for 
Drinking Purposes. By Charles Ekin. Second Edition. i2mo. Price .75 

ELLIS, DISEASES OF CHILDREN. 

A Practical Manual of the Diseases of Children, with a Formulary. By Ed- 
ward Ellis, m.d. Late Physician to the Victoria Hospital for Children, 
London. Fourth Edition 'Enlarged. Now Ready. Price $3.50 

BY SAME AUTHOR. 

WHAT EVERY MOTHER SHOULD KNOW. 

i2mo. Price .75 

" It is only too true that our children have to dodge through the early part of life as through a labyrinth. We 
must be thankful to meet with such a sensible guide for them as Dr. Ellis." — Pall Mall Gazette. 

FENNER, ON VISION. 

Vision ; Its Optical Defects, the Adaptation of Spectacles, Defects of Accommo- 
dation, etc. By C. S. Fenner, m.d. With Test Types and 74 Illustrations. 
8vo. Price $3.50 

FENWICK, THE PRACTICE OF MEDICINE. 

Outlines of the Practice of Medicine. With Appropriate Formulas and Illus- 
trations. By Samuel Fenwick, m.d., Physician to the London Hospital. i2mo. 

Price $2.00 

" This little work displays a sound judgment in the arrangement of its subject matter, and an intimate acquaint- 
ance with the practice of medicine possessed by but few writers, and should have been elaborated into a more 
comprehensive work. Of all the hand-books we have seen, this is certainly one of the best." — Medical Herald. 

" It is an eminently' practical little treatise, pervaded with much common sense, and will doubtless be found 
useful, particularly by advanced students." — Boston Medical and Surgical Journal. 

BY SAME AUTHOR. 

ON THE STOMACH. 

The Morbid State of the Stomach and Duodenum, and Their Relations to 
Diseases of Other Organs. With 10 Plates. 8vo. Price $4- 2 5 

Atrophy of the Stomach and Its Effect on the Nervous Affections of the Digest- 
ive Organs. 8vo. Price $3.20 



FOTHERGILL, ON THE HEART. Second Edition. 

The Heart and Its Diseases. With Their Treatment. Including the Gouty 
Heart. By J. Milner Fothergill, m.d., Associate Fellow of the College of 
Physicians of Philadelphia. Second Edition, Entirely Re-written. Octavo. 

Price $3.50 



" It is the best, as well as the most recent work on 
the subject in the English language." — Medical Press 
and Circular. 

" The most interesting chapter is undoubtedly that 
on the gouty heart, a subject which Dr. Fothergill has 
specially studied, and on which he entertains views 
such as are likely, we think, to be generally accepted 
by clinical physicians, although they have not before 
been stated, so far as we are aware, with the same 
breadth of view and extended illustration." — British 
Medical Journal. 



" To many an earnest student it will prove a light in 
darkness; to many a practitioner cast down with a 
sense of his powerlessness to cope with the rout and 
demoralization of Nature's forces, a present help in 
time of trouble." — Philadelphia Medical Times. 

" The work throughout is a masterpiece of graphic, 
lucid writing, full of good, sound teaching, which will 
be appreciated alike by the practitioner and the stu- 
dent." — Students' Journal. 



FULTON, ON PHYSIOLOGY. 

A Text-Book of Physiology. By J. Fulton, m.d., Professor at Trinity 
Medical College, Toronto. Second Edition, Illustrated and Revised. 8vo. 

Price $4.00 



16 PRESLE Y BLAKIS TON'S 

FLOWER, DIAGRAMS OF THE NERVES, 

Diagrams of the Nerves of the Human Body. Exhibiting their Origin, 
Divisions, and Connections, with their Distribution to the various Regions of the 
Cutaneous Surface, and to all the Muscles. By William H. Flower, f.r.c.s., 
F.R.S., Hunterian Professor of Comparative Anatomy, and Conservator of the 
Museum of the Royal College of Surgeons. Third Edition, thoroughly revised. 
With six Large Folio Maps, or Diagrams. Royal Quarto. Price $3.50 

" Admirably arranged, and will be of incalculable aid to the student of anatomy. Each of the large and 
beautiful plates is accompanied with explanatory text." — JV. Y. Medical Record. 

" The nerves and ganglia are clearly represented. The impressions are well made, and no doubt the diagrams 
will prove useful." — Medical and Surgical Reporter . 

FLAGG, PLASTIC FILLING. 

Plastics and Plastic Filling; As Pertaining to the Filling of all Cavities of De- 
cay in Teeth below Medium in Structure, and to Difficult and Inaccessible 
Cavities in Teeth of all Grades of Structure. With some beautifully executed 
Illustrations. By J. Foster Flagg, d.d.s., Professor of Dental Pathology and 
Therapeutics in Philadelphia Dental College. Octavo. Price $3.00 

Contents. — Introductory. Article i. Plastic Filling. 2. Amalgam. 3. Amalgam continued. 4. Amalgam 
continued. 5. Attributes of Metals used for Amalgam Alloys. 6. The Making of Amalgam Alloys. 7. Tests 
for Amalgam. 8. Preparation of Cavities. 9. The Making of Amalgam. 10. Instrument for the Insertion of 
Amalgam Fillings. 11. The Insertion of Amalgam Fillings. 12. General Considerations Pertaining to Amalgam. 
13. Gutta-percha. 14. Oxy-chloride of Zinc. 15. Oxy-sulphate of Zinc. 16. Zinc Phosphate. 17. Temporary 
Stopping. 18. Technicalities. Conclusion. 

FOSTER, CLINICAL MEDICINE. 

Lectures and Essays on Clinical Medicine. By Balthazar Foster, m.d. 
Illustrated. 8vo. Price $3.00 



"No one can peruse the thoughtful comments of our 
author upon every subject he considers, without feeling 
himself a wiser man for his pains." — N. Y. Medical 
journal. 



" Jt is the record of honest work, such as Dr. Foster 
may be proud of; we can recommend it to the profession; 
it may be read with profit and advantage by both prac- 
titioner and student. — Edinburgh Medical Journal. 

FOX, ATLAS OF SKIN DISEASES. 

Complete in Eighteen Parts, each containing Four Chromo-Lithographic Plates, 
with Descriptive Text and Notes upon Treatment. In all 72 large colored Plates. 
By Tilbury Fox, m.d.,f.r.cp., Physician to the Department for Skin Diseases 
in University College Hospital. Folio Size. 

Price $2.00 each, or complete, bound in cloth, $30.00 

No Atlas of Skin Diseases has been issued in this country for many years, and no 
complete work of the kind is now procurable by the Profession. This one, brought 
out under the editorial supervision and care of Dr. Tilbury Fox (the most distin- 
guished writer on Cutaneous Medicine now in the English language), is partly based 
upon the classical work of Willan and Bateman (now entirely out of print), but com- 
pletely remodeled, so as to represent fully the Dermatology of the present day. 

" Preference will be given to this work over Hebra; not simply, however, because it is a home production, but 
by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates. 
. The letter-press is entirely new. In the accuracy of the latter the subscriber may have the fullest confi- 
dence, since it is from the pen of Dr. Tilbury Fox."— British and Foreign Medico- Chirurgical Review. 

FRANKLAND, WATER ANALYSIS. 

Water Analysis, For Sanitary Purposes, with Hints for the Interpretation of 
Results. By E. Frankland, m.d., f.r.s. Illustrated. i2mo. Price $1.00 



" The author's world-wide reputation will commend 
this manual to all sanitarians, and they will not be dis- 
appointed in finding all the essentials of the important 



"The work is one which physicians practicing in 
the country and in villages and towns remote from 
medical centres cannot afford to be without."— Medical 



subject of which it treats."— The Sanitarian. and Surgical Reporter. 

BY SAME AUTHOR. 

CHEMISTRY. 

How to Teach Chemistry; being Six Lectures to Science Teachers. Edited 
by G. George Chalo^er, f.c.s. Illustrated. i2mo. Price $1.25 



PUB LIC A TIONS. 



17 



FOX, WATER, AIR AND FOOD. 

Sanitary Examinations of Water, Air and Food. 
m.d. 94 Engravings. 8vo. 



By Cornelius B. Fox, 
Price $4.00 



GALLABIN, diseases of women 

The Student's Guide to the Diseases of Women. 
M.D., f.r.c.p. Illustrated with 63 Engravings. 



"Among all the various works on diseases of women 
with which we are acquainted, there is none which so 
nearly approaches the perfection of what a student's 
text-book should be . . . The work is well illustrated." 
— Students' Journal. 

" Though the book is a small one and the subject ex- 
tensive, yet so admirable is the style of the writer, and 
so careful his selection of words, that each disease is 
thoroughly treated of." — Philadelphia Medical Times. 



By A. Lewis Gallabin, m.a., 
i2mo. Price $2.00 

" Its style is clear, elegant, and concise. It contains 
a great amount of information ; indeed, we do not think 
the student or practitioner will find any book which 
will convey to him in so small a compass so much accu- 
rate knowledge about the pathology and diagnosis of 
the diseases peculiar to women." — Medical Times and 
Gazette. 



GROSS, BIOGRAPHY OF JOHN HUNTER. 

John Hunter and His Pupils. By S. D. Gross, m.d., Professor of Surgery in 
Jefferson Medical College, Philadelphia. With a beautifully executed full length 
Portrait of the Author in his Study. A Handsome Octavo volume. Bound in 
Beveled Cloth. Price $ 1.50 

" It is refreshing to read the story of a life so fully devoted to science, and the reader will readily appreciate 
Professor Gross's enthusiasm for his subject, which led him to extend what was originally intended for an essay to 
its present size. 

'• The phototype of Sharp's well-known engraving of Sir Joshua Reynold's portrait is an excellent reproduction, 
and forms a fitting and handsome frontispiece. 

" The volume will prove an ornament to the study table, where it will be a constant incentive to whatever is 
best and noblest in a noble profession." — Boston Med. and Surgical Journal. 

BY SAME AUTHOR. 

AMERICAN MEDICAL MEN. 

American Medical Biography of the Nineteenth Century, with portrait of Dr. 
Benjamin Rush. Large 8vo. Price $3.50 

GANT, A SYSTEM OF SURGERY. Enlarged Edition. 

The Science and Practice of Surgery, including Special Chapters by different 
Authors. By Frederick James Gant, f.r.c.s., Senior Surgeon to the Royal 
Free Hospital. Second Edition, rewritten and much enlarged throughout. 
Illustrated by 969 wood engravings. In two Octavo volumes. 

Price, Cloth $11.00; Leather $13.00 

" This new and magnificent work on surgery sup- 
plies all that can be required, whether for the most com- 
plete study or for constant reference in practice." — 
London Medical Press and Circular. 

" The reader has the advantage of mature experience 
in treating of special subjects, that are either omitted 
or very lightly referred to in ordinary works on sur- 
gery." — London Lancet. 



" After the most patient analysis our limited time 
has permitted, we feel compelled to say that this book 
is a valuable and «omprehensive addition to the surgical 
literature of the profession and a monument to the care- 
ful, conscientious and painstaking industry of the 
author." — Cincinnati Lancet and Observer. 



BY SAME AUTHOR. 



ON THE BLADDER AND PROSTATE. 

Diseases of the Bladder and Prostate Gland and Urethra, including a Practical 
View of Urinary Diseases, Deposits and Calculi. Fourth Edition, Revised and 
Enlarged, with New Illustrations. i2mo. Price $3.00 



GIBBES, STUDENT'S PATHOLOGY. 

Practical Histology and Pathology. By Heneage Gibbes, m.b. i2mo. 
Cloth. Price $1.00 

Chap. i. Introduction. 2. On Preparing Tissues for Examination. 3. On Cutting Sections. 4. On Staining. 
5. On Double Staining. 6. On Mounting. 7. Method of Obtaining Animal Tissues, etc. Practical Histology, 
Pathoiogy, Memoranda and Formulae. 

" This excellent little work is admirably adapted to fulfill the purpose for which it has been written. It is 
short, clear, and eminently practical. The author is evidently an accomplished histologist, and his book conveys 
the impression that it is based upon his own personal experience." — The London Medical Record. 



18 PRESLE Y BLAKISTON 'S 

GODLEE'S ATLAS OF HUMAN ANATOMY. 

Illustrating most of the Ordinary Dissections and many not usually practiced 
by the Student. Accompanied by References and an Explanatory Text. Com- 
plete. Folio Size. 48 Colored Plates. By Rickman John Godlee, m.d., 
f.r.c.s. Forming a large Folio Volume, with References, and an Octavo 
Volume of Letter-press. 

Price of the two Volumes, Atlas and Letter-press, Cloth, $30.00 



" It is likely to prove as useful to the physician and 
surgeon as to the anatomist." — Medical Times and 
Gazette. 



" The explanatory text is concise, well written, and 
contains many valuable suggestions for the surgeon." 
— London Lancet. 



GOWERS, SPINAL CORD. 

Diagnosis of Diseases of the Spinal Cord. With Colored Plates and Engrav- 
ings. A Second Edition. Revised and Enlarged. By William R. Gowers, 
m.d., Assistant Professor Clinical Medicine, University College, London. 8vo. 

Price $1.50 

BY SAME AUTHOR. 

OPHTHALMOSCOPY. 

A Manual and Atlas of Medical Ophthalmoscopy. With 16 Colored Auto* 
type and Lithographic Plates and 26 Wood Cuts, comprising 112 Original Illus- 
trations of the Changes in the Eye in Diseases of the Brain, Kidneys, etc. 8vo. 

Price #6.00 
GREENHOW, BRONCHITIS. 

On Chronic Bronchitis, especially as connected with Gout, Emphysema, and 
Diseases of the Heart. By E. Headlam Greenhow, m.d. i2mo. Price #1.50 

BY SAME AUTHOR. 

ADDISON'S DISEASE. 

Being the Croonian Lectures, delivered before the Royal College of Physi- 
cians, London. Revised and Illustrated by Plates and Reports of Cases. 8vo. 

Price $3.00 

"The hook forms a most interesting and valuable monograph, comprehensive and exhaustive." — British 
Medical "Journal. 

GLISAN, TEXT-BOOK OF MODERN MIDWIFERY. 

A Text-Book of Modern Midwifery. By Rodney Glisan, m.d., Emeritus 
Professor of Midwifery and Diseases of Women and Children in the Medical 
Department of Willamette University, Portland, Oregon, and Late President 
of the Oregon State Medical Society. With 129 Illustrations. One Volume, 
octavo, 624 pp. Price, in Cloth $4.00; in Leather $5-oo 

Many years have elapsed since the appearance of an original American text-book 
of obstetrics. The author of this one, believing that there is a demand for a work 
thoroughly representing American obstetrical practice, ventures to present this con- 
densed treatise to the medical students and practitioners of his own country. Many 
years' experience as a practitioner and several as a teacher of midwifery, warrants 
this effort to supply the demand for a book fully brought up to the present time, 
faithfully representing the peculiarities of American practice, and adapted to the wants 
of obstetric teachers and busy practitioners. 

The book is freely illustrated wherever its value and usefulness can be thus en- 
hanced, and being brought out — owing to the unavoidable absence of the author — 
under the supervision of the well-known obstetrician, Dr. Robert P. Harris, of 
Philadelphia, the publishers very confidently anticipate for it a favorable reception. 

GILL, ON INDIGESTION. Second Edition. 

Indigestion ; What It Is ; What It Leads To ; and a New Method of Treating 
It. By John Beadnell Gill, m.d. Second Edition. 121110. Price $1.25 



PUB LIC A TIONS. 



19 



HABERSHON, ON THE STOMACH. 

On Diseases of the Stomach — The Varieties of Dyspepsia — Their Diagnosis 
and Treatment. By S. O. Habershon, m.d., f.r.c.p., Senior Physician to, and 
Late Lecturer on, the Principles and Practice of Medicine at Guy's Hospital. 
Third Edition, Revised. Crown 8vo. Price $1.75 

" As an expression of the results of long personal experience in both hospital and private practice, conveyed in 
agreeable though not always perspicuous diction, this contribution of Dr. Habershon's has special value of its 
own, and is so far entitled to the favorable consideration of the practitioner, as is already testified by a demand for 
a third edition." — American youmal of Medical Sciences. 

" It is divided into twenty chapters, fifteen of which are devoted to a consideration of the different forms of 
Dyspepsia, while the remaining treat of Degeneration, Ulceration, Cancerous Diseases, and Spasms of the 
Stomach." We can cordially recommend this book of Dr. Habershon's to the profession." — Medical Record. 

HALE, ON CHILDREN. 

The Management of Children in Health and Disease. A Book for Mothers. 
By Mrs. Amie M. Hale, m.d. Abounding in valuable information and com- 
mon-sense advice. New Enlarged Edition. i2mo. Price .75, 

" We shall use our influence in the introduction of this work to families under our care, and we urge the profession 
generally to follow our example." — Buffalo Medical and Surgical Journal. 

HARDWICH AND DAWSON, PHOTOGRAPHIC CHEMIS- 
TRY. 

Hardwich's Manual of Photographic Chemistry. Illustrated. Eighth Edition.. 
Rearranged by G. Dawson. i2mo. Price #2.00 

HARDWICKE, MEDICAL EDUCATION. 

Medical Education and Practice in All Parts of the World. Containing 
Regulations for Graduation at the Various Universities throughout the World. 
By Herbert Junius Hardwicke, m.d., m.r.c.p. 8vo. Price $3.00" 

" Dr. Hardwicke's book will prove a valuable source of information to those who may desire to know the 
conditions upon which medical practice is or may be pursued in any or every country of the world, even to the 
remotest corners of the earth. The work has been compiled with great care, and must have required a vast 
amount of labor and perseverance on the part of its author." — Dublin Medical Journal. 

HARRISON, STRICTURE OF THE URETHRA. 

On Stricture and Other Diseases of the Urinary Organs. By Renegall 
Harrison, f.r.c.s. With numerous Illustrations. 8vo. Price $2.7$ 

HAYDEN, ON THE HEART. 

The Diseases of the Heart and Aorta. By Thomas Hayden, m.d. With 81 
Illustrations. 2 vols. 1232 pp. 8vo Price $6.00 

" The author evidently has had a very wide and well used experience in that of which he writes ; is well versed 
in modern physiology and pathology, and holds a fluent pen, consequently the book is an excellent one, and as 
the teachings of the text are abundantly illustrated by the reports of one hundred and fifty cases, Dr. Hayden's 
effort will probably attain the popularity it deserves." — Philadelphia Medical Times. 

" There is not an unnecessary page in Dr. Hayden's work." — N. Y. Medical Record. 

HOLDEN, HUMAN OSTEOLOGY. Sixth Edition. 

Comprising a Description of the Bones, with Colored Delineations of the At- 
tachments of the Muscles. The General and Microscopical Structure of Bone 
and its Development. By the Author and A. Doran, f.r.c.s., with Lithographic 
Plates, etc. By Luther Holden, f.r.c.s. Numerous Illustrations. Sixth 
Edition, carefully Revised. Price $5.50 

BY SAME AUTHOR. 

ANATOMY. 

Manual of Dissections of the Human Body. Fourth London Edition. With 
170 Illustrations. Price $5.50 

LANDMARKS. 

Landmarks, Medical and Surgical. Third London Edition. Revised and 
Enlarged. Price $1.25 

" Mr. Holden is the happy possessor of the faculty of writing interesting works on Anatomy. A part of the 
charm consists in the frequent references to practical points, and in the explanation of the advantages and objects 
of details of structures." — Bosten Medical and Surgical Journal. 



20 PRESLE Y BLAKISTON'S 

HEATH'S OPERATIVE SURGERY. 

A Course of Operative Surgery, consisting of a Series of Plates, each plate 
containing Numerous Figures, Drawn from Nature by the Celebrated Anatomi- 
cal Artist, M. Leveille, of Paris, Engraved on Steel and Colored by Hand, 
under his immediate superintendence, with Descriptive Text of Each Operation. 
By Christopher Heath, f.r.c.s., Surgeon to University College Hospital, and 
Holme Professor of Clinical Surgery in University College, London. One Large 
Quarto Volume. Price $14.00 

The author has embodied in this work the experience gained by him during 
twenty years of surgical teaching. It comprises all the operations that are required 
in ordinary surgical practice. He has selected for illustration and description those 
methods which appear to give the best results in practice, referring to the errors 
likely to occur and the best methods of avoiding them. 

BY SAME AUTHOR. 

THE STUDENT'S GUIDE TO SURGICAL DIAGNOSIS. 

i2mo. Price $1.50 

" Mr. Heath is so well known, both as a practical surgeon, teacher and writer, that anything from his pen re- 
quires no introduction from the hands of reviewers, and scarcely any notice but the announcement of the fact that 
he has written a book." — Medical Record. 

A MANUAL OF MINOR SURGERY AND BANDAGING. 

Sixth Edition, Revised and Enlarged. With 115 Illustrations. i2mo. 

Price $2.00 

" This excellent work should not be termed a ' Minor' Surgery, but it really consists qf the sum and substance 
of Practical surgery. We would not exchange it for any book in our possession." — Southern Clinic. 

HEATH'S PRACTICAL ANATOMY. Fifth London Edition. 

Practical Anatomy. A Manual of Dissections. Fifth London Edition. 24 
Colored Plates, and nearly 300 other Illustrations. Just Ready. Price $5.00 

INJURIES AND DISEASES OF THE JAWS. 

The Jacksonian Prize Essay of the Royal College of Surgeons of England, 
1867. Second Edition, Revised, with over 150 Illustrations. Octavo. 

Price $4.25 
HOOD, ON GOUT AND RHEUMATISM. 

A Treatise on Gout, Rheumatism, and the Allied Affections. Their Treat- 
ment, Complications, and Prevention. By Peter Hood, m.d. Second Edi- 
tion, Revised and Enlarged. With some Considerations on Longevity. Octavo. 

Price $3.50 

" The Observations on Treatment are specially to be commended." — London Lancet. 

HOLDEN, THE SPHYGMOGRAPH. 

The Sphygmograph. Its Physiological and Pathological Indications. By 
Edgar Holden, m.d. Illustrated by Three Hundred Engravings on Wood. 
8vo. Price $ 2 -°° 

HOLMES, THE LARYNGOSCOPE. 

A Guide to the Use of the Laryngoscope in General Practice. By Gordon 
Holmes, m.d., Physician to the Throat and Ear Infirmary. i2mo. Price $1.00 

BY SAME AUTHOR. 

VOCAL PHYSIOLOGY. 

Vocal Physiology and Hygiene. With reference to the Cultivation and 
Preservation of the Voice. Illustrated. i2mo. Price $2.00 

HOFF, ON HEMATURIA. 

Hsematuria as a Symptom of the Diseases of the Genito-Unnary Organs. By 
O. Hoff, m.d. Illustrated. i2mo. Pnce -75 



PUB LIC A TIONS. 2 1 

HUNTER, MECHANICAL DENTISTRY. 

A Practical Treatise on the Construction of the Various kinds of Artificial 
Dentures, with Formulae, Receipts, etc. By Charles Hunter, d.d.s. 100 
Illustrations. i2mo. Price $2.25 

" It is the outcome of his own experience of some twenty years as a Mechanical Dentist, and contains, moreover, 
much derived from practical knowledge of other dentists. The value of the book is also much added to by illus- 
trations. It will be very useful to the Dental Student, and to all Mechanical Dentists." — London Medical Times 
*nd Gazette. 

HUTCHINSON'S ILLUSTRATIONS OF CLINICAL SUR- 
GERY. First Volume Complete. 

Consisting of Plates, Photographs, Woodcuts, Diagrams, etc. Illustrating 
Surgical Diseases, Symptoms, and Accidents; also Operations and other 
Methods of Treatment. With Descriptive Letter-press. By Jonathan Hutch- 
inson, f.r.c.s., Senior Surgeon to the London Hospital, Surgeon to the Moor- 
fields Ophthalmic Hospital, and to the Hospital for Diseases of the Skin, Black- 
friars. In Quarterly Fasciculi. Imperial 4to. Volume 1. (Ten Fasciculi) bound 
complete in itself. Price $25.00. Parts Eleven, Twelve, Thirteen, and Fourteen 
of Volume 2, Now Ready. Each $2.50 

HEWITT, DISEASES OF WOMEN. Third Edition. 

The Diagnosis, Pathology, and Treatment of Diseases of Women, Including 
the Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St. 
Mary's Hospital Medical School. By Graily Hewitt, m.d., Lond., m.r.c.p., 
Physician to the British Lying-in Hospital ; Lecturer on Midwifery and Diseases 
of Women and Children at St. Mary's Hospital Medical School; Honorary 
Secretary to the Obstetrical Society of London, etc. The Third Edition. Re- 
vised and Enlarged, with New Illustrations. Octavo. 

Price, Cloth $4.00; Leather $5.00 



" Readers of the former editions will not require to 
be told that the additions now made are of the highest 
possible excellence." — Times and Gazette. 

" It is one of the most useful, practical, and compre- 
hensive works upon the subject in the English language, 
a true guide to the student, and an invaluable means of" 
reference for the teacher." — N. Y. Medical Record. 



" The excellent work of Dr. Hewitt presents — in a 
form well adapted to conduct the student to a knowledge 
of the Diseases of Women, and to assist the young 
practitioner in his study of these diseases at the bedside 
of the patient — a very full and clear exposition of the 
views entertained by the most authoritative teachers as 
to their pathological treatment and their correct Diag- 
nosis." — Amer. Med. Journal. 

HAY, SARCOMATOUS TUMOR. 

History of a Case of Recurring Sarcomatous Tumor of the Orbit in a Child. 
By Thomas Hay, m.d. Illustrated. Paper. Price .50 

HEWSON, EARTH IN SURGERY. 

Earth as a Topical Application in Surgery, Being a Full Exposition of its Use 
in Cases Requiring Topical Applications. By Addinell Hewson, m.d. Illus- 
trated. 8vo. Price #2.50 

HODGE, ON ABORTION. 

On Foeticide or Criminal Abortion. By Hugh L. Hodge, m.d. 

Price, Paper, .30; Cloth, .50 
HODGE, CASE-BOOK. 

Note-Book for Cases of Ovarian Tumors. By H. Lennox Hodge, m.d. With 
Diagrams. Price, Paper, .50 

HIGGINS, DISEASES OF THE EYE. 

A Hand-Book of Ophthalmic Practice. By Charles Higgins, f.r.c.s. 
Ophthalmic Assistant Surgeon at Guy's Hospital. Second Edition. i6mo. 

Price .60 

Contents. — Section i. Discharge from the Eyes. n. Intolerance of Light, in. Iritis and Glaucoma, iv. 
Diseases of the Eyelids. V. Watering of the Eye. vi. Acuteness a£ Vision, Field of Vision, Anomalies of Re- 
fraction, Astigmatism, Accommodation, Presbyopia, vn. Disturbance of Vision, Use of the Ophthalmoscope, 
Normal and Morbid Appearances, vm. Injuries. 

"We have rarely seen so much important information condensed in so short a space." — American Medical 
Journal. 



22 PRESLE V BLAKISTON'S 

HARRIS, THE PRACTICE OF DENTISTRY. Tenth Edition. 

The Principles and Practice of Dentistry. Tenth Revised Edition. In great 
part Rewritten, Rearranged, and with many new and important Illustrations. 
By Chapin A. Harris, m.d., d.d.s. Edited by P. H. Austen, m.d., Professor 
of Dental Science and Mechanism in the Baltimore College of Dental Surgery. 
With nearly 400 Illustrations. Royal Octavo. Price, Cloth, #6.50 ; Leather, $7.50 

This new edition of Dr. Harris" work has been thoroughly revised in all its parts, 
more so than any previous edition. So great have been the advances in many 
branches of dentistry that it was found necessary to rewrite the articles or subjects, 
and this has been done in the most efficient manner by Professor Austen, for many 
years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas 
S. Latimer, m.d. The publishers feel assured that it will now be found the most 
complete text-book for the student, and guide for the practitioner in the English 
language. 

BY SAME AUTHOR. 

MEDICAL AND DENTAL DICTIONARY. Fourth Edition. 

A Dictionary of Medical Terminology, Dental Surgery, and the Collateral 
Sciences. Fourth Edition, Carefully Revised and Enlarged. By Ferdinand 
J. S. Gorgas, m.d., d.d.s., Professor of Dental Surgery in the Baltimore College, 
etc. Royal Octavo. Price, Cloth, $6.50; Leather, $7.50 

This Dictionary, having passed through three editions, and been for some time 
out of print, has been again carefully revised by F. J. S. Gorgas, m.d., Dr. Harris' 
successor as Professor of Dental Surgery in the Baltimore College of Dental Surgery. 
In his preface to this new edition, the editor says : — 

" The object of the reviser has been to bring the book thoroughly up to the pres- 
ent requirements of the profession, the Medical portion having been as carefully re- 
vised and added to as that devoted more especially to Dental Science, while a 
number of obsolete terms and methods have been omitted. In nearly every one of 
the seven hundred and forty-three pages of the former edition corrections and addi- 
tions have been made, and many new processes, terms and appliances described, 
some of which are not found in any other work published." 

HANDY, ANATOMY. 

Text-Book of Anatomy and Guide to Dissections. For the Use of Students. 
By W. R. Handy, m.d. 312 Illustrations. Price $3.00 

HILLIER, DISEASES OF CHILDREN. 

A Clinical Treatise on the Diseases of Children. By Thomas Hillier, m.d. 
8vo. Price $2.00 

HUFELAND, LONG LIFE. 

The Art of Prolonging Life. By C. W. Hufeland. Edited by Erasmus 
Wilson, m.d. i2mo. Price $1.0© 

" We wish all doctors and all their intelligent clients would read it, far surely its perusal would be attended 
with pleasure and benefit." — American Practitioner. 

" It certainly should be in the library of every physician." — Medical Brief. 

HUNTER, PORTRAIT OF. 

Portrait of John Hunter. From Sharp's well-known Engraving ; a copy of 
Sir Joshua Reynold's Portrait. For Framing. Large size, 9x11; sheet 16 x 20. 
Price, in the Sheet, sent free by mail, 50 cents ; or, Handsomely Framed^ 

Price $2.00 



PUBLICATIONS. 23 



HEADLAND, THE ACTION OF MEDICINES. Sixth Edition. 

On the Action of Medicines in the System. By F. W. Headland, m.d. 
Sixth American Edition, Revised and Enlarged. 8vo. Price $3.00 

" It displays in every page the evidence of extensive knowledge and of sound reasoning; it will be useful alike 
to those who are just commencing their studies, and to those who are engaged in the active pursuits of pro- 
fessional life." — Medical Times. 

" The very favorable opinion which we were amongst the first to pronounce upon this essay has been fully 
confirmed by the general voice of the profession, and Dr. Headland may now be congratulated on having pro- 
duced a treatise which has been weighed in the balance, and found worthy of being ranked with our standard 
medical works." — London Lancet. 

JAMES, SORE THROAT. 

On Sore Throat, Its Nature, Varieties and Treatment, Including its Con- 
nection with other Diseases. By Prosser James, m.r.c.p. Fourth Edition, 
Revised and Enlarged. With Colored Plates and Numerous Wood-cuts. i2mo. 

Price $2.25. 

" We can confidently recommend his therapeutic teachings as well worthy of the careful consideration of the 
Profession, for they set forth the practice of an enthusiastic worker, whose special experience has been large and 
lengthened." — British Medical Journal. 

" The practitioner who buys Dr. James' unpretending little book will provide himself with a wise and practical 
clinical commentary, and with a well arranged digest of long and varied experience." — Westminster Review. 

BY SAME AUTHOR. 

LARYNGOSCOPY AND RHINOSCOPY. 

Including the Diagnosis of Diseases of the Throat and Nose. Third Edition. 
With Colored Plates. i8mo. Price $2.00. 

" It gives in a succinct form the approved methods of examination and treatment of diseases of the nose, throat, 
and larynx. The plan pursued is one well adapted to the needs of the general practitioner." — American Medical 
Journal. 

JONES, AURAL ATLAS. 

An Atlas of Diseases of the Membrana Tympani. Being a Series of Colored 
Plates, containing 62 Figures. With appropriate Letter-press and Explanatory 
Text. By H. Macnaughton Jones, m.d., Surgeon to the Cork Ophthalmic and 
Aural Hospital. 4*0. Price $6.00. 

" The cases are well selected, the drawings executed from life, highly artistic and very conscientious, and the 
commentaries indicate familiarity with the subject and good judgment in dealing with it." — British Medical 
Journal. 

BY SAME AUTHOR. 

AURAL SURGERY. 

A Practical Hand-Book on Aural Surgery. Illustrated. i2mo. Price $1.50. 

JONES, SIEVEKING AND PAYNE, PATHOLOGICAL AN- 
ATOMY. 

A Manual of Pathological Anatomy. By C. Handfield Jones, m.d., and 
Edward H. Sieveking, m.d., Physician to St. Mary's Hospital. A New En- 
larged Edition. Edited by J. F. Payne, m.d., Lecturer on Morbid Anatomy at 
St. Thomas' Hospital. With Numerous Illustrations. Demi 8vo. Price $5.50. 

JONES, ON, SIGHT AND HEARING. 

The Defects of Sight and Hearing, their Nature, Causes, and Prevention. By 
T. Wharton Jones, m.d. Second Edition. i6mo. Price .50. 

KIRBY, ON PHOSPHORUS. Fifth Edition. 

Phosphorus as a Remedy for Functional Diseases of the Nervous System. 
By E. A. Kirby, m.d. Fifth Edition. 8vo. Price $1.00 

KOLLMEYER, KEY TO CHEMISTRY. 

Chemia Coartata, or Key to Modern Chemistry. By A. H. Kollmeyer, m.d. 
With Numerous Tables, Tests, etc. Price $2.25 

KIRKE, PHYSIOLOGY. Revised up to 1881. 

A Hand-book of Physiology. By Kirke. Tenth London Edition. By W. 
Morrant Baker, m.d. 420 Illustrations. Price $5.00 



24 PRESLEY BLAKISTON'S 



KANE, THE OPIUM, MORPHINE AND SIMILAR HABITS. 

Drugs that Enslave. The Opium, Morphine, Chloral, Hashisch and Similar 
Habits. By H. H. Kane, m.d., of New York. With Illustrations. Price $1.50 

" It contains a large amount of information collected with much labor and presented In a systematic manner. 
The subject of the chloral habit has not been investigated by any one, we believe, so thoroughly as Dy Dr. Kane." 
— Medical Record. 

" It deserves to be read by those who feel an interest in discouraging the use of these dangerous drugs. The 
book is embellished by an excellent phototype frontispiece of Laocoon." — American Journal of Pharmacy. 

" A work of more than ordinary ability and careful research. . . . For the first time, reliable statistics on 
the use of chloral are classified and published, . . . and it is shown that the use of chloral causes a more 
complete a?id rapid ruin of mind and body than either opium or morphine." — Druggists' Circular and Gazette. 

KIDD, THERAPEUTICS. 

The Laws of Therapeutics ; or, the Science and Art of Medicine. By Joseph 
Kidd, m.d. i2ino. Cloth. Price $1.25. 

Dr. Joseph Kidd, who, by the way, was Lord Beaconsfield's medical adviser, and 
an eminent physician of the regular school, briefly but clearly sketches the history of 
medicine from the earliest period. He shows that the chief mistakes have been 
made through deference to theory and negligence of the teachings of facts. Thence 
he passes to an assertion of the value of the homoeopathic principle of similia simili- 
bus in the treatment of many diseases. He is not a follower of Hahnemann, and 
does not believe in innnitessimal doses, but he claims, and enforces his position by 
the citation of cases in his own practice, that the homoeopathic principle has performed 
wonders where that of his own school was much less successful. 

" Dr. Kidd acknowledges two laws — that of contraria contrariis and similia similibus ; but the cases he gives 
in his chapter on ars medica show that, like a sensible practitioner, he does not allow himself blindly to follow 
either the one or the other, but seeks out the cause of disease, and tries by rational measures to remove it. The 
cases are the most valuable part of the book." — London Practitioner . 

LEGG, ON THE URINE. 

Practical Guide to the Examination of the Urine, for Practitioner and Student. 
By J. Wickham Legg, m.d. Fifth Edition, Enlarged. Illustrated. i2mo. 

Price .75 

This little work is intended to supply the Physician or Student with a concise guide 

to the recognition of the different characteristics of the urine, and though small and 

well adapted to the pocket, contains, probably, everything that could be gleaned 

from a larger work. 

LEARED, IMPERFECT DIGESTION. 

The Causes and Treatment of Impeifect Digestion. By Arthur Leared, m.d. 
The Sixth Edition. Revised and Enlarged. i2mo. Price $1.50 

LIEBREICH, ATLAS OF OPHTHALMOSCOPY. 

An Atlas of Ophthalmoscopy, containing 12 Full-page Chromo-Lithographic 
Plates, with 59 Figures. By R. Liebreich, m.d. Second Edition, Enlarged. 
Large Quarto. Price $12.00 

LIVEING, ON SICK HEADACHE. 

Megrim, or Sick Headache and Some Allied Disorders. By Edward Live- 
ing, m.d. With Plates, Tables, etc. 8vo. Price $5.50 

LEBER AND ROTTENSTEIN, DENTAL CARIES. 

Dental Caries and Its Causes. An Investigation into the Influence of Fungi 
in the Destruction of the Teeth. By Drs. Leber and Rottenstein. Illustrated. 
8vo. Price $1.25 

" The work gives the result of patient observation, presents the deductions of its authors with a perspicuity and 
modesty calculated to secure for its positions a thoughtful consideration. We heartily commend it as an educa- 
tional work." — Dental Cosmos. 



PUBLICA TIONS. 



25 



LEWIN, ON SYPHILIS. 

The Treatment of Syphilis. By Dr. George Lewin, of Berlin. Translated 
by Carl Proegler, m.d., and E. H. Gale, m.d., Surgeons U. S. Army. Illus- 
trated. i2mo. Price $1.50 

"When such authorities as Dr. Drysdale (as we quoted a few weeks ago) condemn the use of mercury in syphilis 
as " too dangerous," while, on the other hand, eminent surgeons, such as Professor Gross, will not treat a case 
without that drug, general practitioners will gladly welcome any media via which gives us all the good effects of 
mercurials without any danger of their ill results appearing. This is what is accomplished by Dr. Lewin." — 
Philadelphia Medical and Surgical Reporter. 

LIZARS, ON TOBACCO. 

The Use and Abuse of Tobacco. 



By John Lizars, m.d. i2mo. Price .50 



LONGLEY, POCKET MEDICAL LEXICON. 

Students' Pocket Medical Dictionary, Giving the Correct Definition and Pro- 
nunciation of all Words and Terms in General Use in Medicine and the Collate- 
ral Sciences, with an Appendix, containing Poisons and their Antidotes, Abbre- 
viations Used in Prescriptions, and a Metric Scale of Doses. By Elias Longley. 
24mo. Price, Cloth, $1.00; Tucks and Pocket $1.25 

This is an entirely new Medical Dictionary, containing some 300 compactly 
printed 24mo pages, very carefully prepared by the author, who has had much ex- 
perience in the preparation of similar works, assisted by the Professors of Chemistry 
and of Botany in one of our leading medical colleges. 



" This little book will be welcomed by students in 
medicine and pharmacy as a convenient pocket com- 
panion, giving the pronunciation, acceptation, and 
definition of medical, pharmaceutical, chemical and 
botanical terms." — American Journal of Pharmacy. 

" It would seem to be just the book for dental and 
medical students."— Dental Advertiser. 



" It is, we believe, also the only lexicon in existence 
in which the pronunciation of words is fully and dis- 
tinctly marked." — Canada Medical Review. 

" This is a very compact and complete little diction- 
ary. We commend it as particularly useful to students." 
— New York Medical Journal. 



MARTIN, ATLAS OF GYNAECOLOGY. 

An Atlas of Obstetrics and Gynaecology. By Prof. A. Martin, of Berlin. 
Translated and edited from the Second German Edition, with additions, by Fan- 
court Barnes, m.d., m.r.c.p. With 98 Full-page Lithographic Plates, con- 
taining over 400 figures, many being colored. With full letter-press references 
to and explanations of each figure ; forming a thick quarto volume. Bound in 
heavy beveled boards. Sold only by subscription. Price $12.00 



""This valuable and classic series of illustrations 
includes 98 pages of plates, with an average of 5 illus- 
trations on each, many of which are colored, and some 
drawn on a large scale, so as to occupy the whole page. 
The subjects treated range through the whole of mid- 
wifery and gynaecology, beginning with normal and ab- 
normal pelvis, and ending with illustrations of some of 
the most important obstetric gynaecologic instruments 
used in Germany and in this country. . . The de- 
scriptive letter-press is vory full and accurate, and the 
whole makes an extremely handsome volume." — Brit- 
ish Medical Jou?nal, July 10th, 1880. 



"The atlas is the most complete and comprehensive 
work of its kind. . . Nearly every point, anatomi- 
cal, physiological, obstetrical, and gynaecological, is 
illustrated in the best way, by well known authors, 
from whose works the late Dr. Martin culled his illus- 
trations. As a work of reference, to the practitioner, 
the atlas is invaluable ; while to the student who wishes 
to refresh his memory in the readiest way and in the 
shortest time, it will be very useful." — London Medi- 
cal Record, July 15th, 1880. 



MACDONALD, MICROSCOPICAL EXAMINATION OF 
WATER. 

A Guide to the Microscopical Examination of Drinking Water. By J. D. 
Macdonald, m.d. With Twenty Full-page Lithographic Plates, Reference 
Tables, etc. 8vo. Price $2.75 

"The volume is an excellent hand-book and will greatly facilitate the study of the subject."-— Popular Science 
Monthly. 

MACEWEN, ON OSTEOTOMY. 

An Inquiry into the Etiology and Pathology of Knock-knee, Bow-leg and 
other Osseous Deformities of the Lower Limbs. By Wm. Macewen, m.d. Il- 
lustrated. 8vo. Price #3.00 



26 PRESLE Y BLAKISTON'S 

MACKENZIE, ON THE THROAT AND NOSE. 

Including the Pharynx, Larynx, Trachea, (Esophagus, Nasal Cavities,, and 
Neck. By Morell Mackenzie, m.d., London, Senior Physician to the Hos- 
pital for Diseases of the Chest and Throat, Lecturer on Diseases of the Throat 
at London Hospital Medical College, etc., etc. Vol. I, containing the Pharynx, 
Larynx and Trachea, with 112 Illustrations. Now ready. 

Price, Cloth, #4.00; Sheep, $5.00 

fi^* Author's Edition, with the Original Illustrations. Published from early 
sheets, by arrangement with Dr. Mackenzie. Vol. 2 in preparation. 

' ' We have long felt the want of a thoroughly practical and systematic treatise on diseases of the throat 
and nasal passages. Admirable essays have from time to time appeared ; no standard work has been written. 
Any one familiar with laryngoscopy work must appreciate the valuable addition now made to this special 
department in the work before us. The entire work will include the consideration of affections of the pharynx, 
larynx, trachea, oesophagus, nasal cavities, and neck. The matter now presented complete for the first time is 
the result of the author's large and unrivaled experience, both in hospital and private practice, extending over 
a period of twenty years. There can be but one verdict of the profession on this manual — it stands without any 
competitor in medical literature, as a standard work on the organs it professes to treat of." — Dublin Journal. 

" It is both practical and learned ; abundantly and well illustrated ; its descriptions of disease are graphic, and 
the diagnoses the best we have anywhere seen. To give examples of the thoroughness of Dr. Mackenzie's book, 
we may cite the chapter on diphtheria, which embraces 47 pages. The chapter on non-malignant tumors of the 
larynx would appear to be absolutely exhaustive. Nowhere else have we seen so elaborate a statement of the sub- 
ject. We can predict for this work a high position, and congratulate its distinguished author upon its appear- 
ance." — Philadelphia Medical Times. 

BY SAME AUTHOR. 

THE PHARMACOPOEIA of the Hospital for Diseases of the 
Throat and Nose. 

The Fourth Edition, much enlarged, containing 250 Formulae, with Directions 
for their Preparation and Use. i6mo. Price $1.25 

DIPHTHERIA. ITS NATURE AND TREATMENT. 

i2mo. Price .75 

Contents. — 1. The Definition and History. 2. The Etiology. 3. The Symptoms. 4. The Paralyses. 5. 
The Diagnosis. 6. The Pathology. 7. The Prognosis. 8. The Treatment. 9. Laryngo-Tracheal Diphtheria. 
10. Nasal Diphtheria. 11. Secondary Diphtheria. 

"The terse remarks on prognosis are excellent; and what the Author says of treatment, general and local, and 
tracheotomy, we commend most cordially." — New York Medical Journal. 

GROWTHS IN THE LARYNX. 

Their History, Causes, Symptoms, etc. With Reports and Analysis of one 
Hundred Cases. With Colored and Other Illustrations. 8vo. Price'$2.oo 

MACNAMARA, DISEASES OF THE EYE. 

A Manual of the Diseases of the Eye. By C. Macnamara, m.d. Third 
Edition, Carefully Revised ; with Additions and Numerous Colored Plates, Dia- 
grams of Eye, Wood-cuts, and Test Types. Demi 8vo. Price $4.00 

"As a book of ready reference on diseases of the eye it has no superior, and we may safely say, no equal in our 
language." — Cincinnati Lancet and Observer. 

BY SAME AUTHOR. 

ON THE BONES AND JOINTS. 

Lectures on Diseases of the Bones and Joints. Second Edition. Demi 8vo. 

Price #4.25 

MADDEN, HEALTH RESORTS. 

Health Resorts for the Treatment of Chronic Diseases. A Hand-Book, the 
result of the author's own observations during several years of health travel in 
many lands, containing also remarks on climatology and the use of mineral 
waters. By T. M. Madden, m.d. 8vo. Price $2.50 

" Rarely have we encountered a book containing so much information for both invalids and pleasure seekers." 
— The Sanitarian. 



PUB LIC A TIONS. 27 



MARSHALL & SMITH, ON THE URINE. 

The Chemical Analysis of the Urine. By John Marshall, m.d., and Edgar 
F. Smith, m.d., of the Chemical Laboratory, Medical Department, University of 
Pennsylvania. Illustrated by Phototype Plates. i2mo. Price $1.00 

MARSHALL, ANATOMICAL PLATES; 

Or Physiological Diagrams. Life Size (7 by 4 feet) and Beautifully Colored. 
By John Marshall, f.r.s. An Entirely New Edition, Revised and Improved, 
Illustrating the Whole Human Body. 
The Set, Eleven Maps, in Sheets, Price $50.00 

handsomely Mounted on Canvas, with 

Rollers, and Varnished, Price $80.00 
An Explanatory Key to the Diagrams, Price .50 

Dr. Marshall's Plates, from their size and perfection of drawing and coloring, excel 
any diagrams that have been published. They have proved invaluable in Medical 
Schools and Lecture Rooms. The low price at which they are offered brings them 
within reach of all. 

No. 1. The Skeleton and Ligaments. No. 2. The Muscles, Joints, and Animal Mechanics. No. 3. The Vis- 
cera in Position — The Structure of the Lungs. No. 4. The Organs of Circulation. No. 5. The Lymphatics or 
Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of the Senses 
and Organs of the Voice, Plate 1. No. 9. The Organs of the Senses, Plate 2. No. 10. The Microscopic 
Structure of the Textures, Plate 1. No. 11. The Microscopic Structure of the Textures, Plate 2. 

MARSDEN, ON CANCER. 

A New and Successful Mode of Treating Certain Forms of Cancer. By Alex- 
ander Marsden, m.d. Second Edition. Colored Plates. 8vo. Price $3.00 

MARTIN, MICROSCOPIC MOUNTING. 

A Manual of Microscopic Mounting. With Notes on the Collection and Ex- 
amination of Objects, and upwards of 150 Illustrations. B> John H. Martin. 
Second Edition, Enlarged. 8vo. Price $2.7$ 

MORRIS, ON THE JOINTS. 

The Anatomy of the Joints of Man. Comprising a Description of the Liga 
ments, Cartilages, and Synovial Membranes; of the Articular Parts of Bones, 
etc. By Henry Morris, f.r.c.s. Illustrated by 44 Large Plates and Numerous 
Figures, many of which are Colored. 8vo. Price $5.50 

MUTER, MEDICAL AND PHARMACEUTICAL CHEMIS- 
TRY. 

An Introduction to Pharmaceutical and Medical Chemistry. Part One. — 
Theoretical and Descriptive. Part Two. — Practical and Analytical. Arranged 
on the principle of the Course of Lectures on Chemistry as delivered at, and the 
Instruction given in the Laboratories of, the South London School of Pharmacy. 
By John Muter, m.d., President of the Society of Public Analysts. A Second 
Edition, Enlarged and Rearranged. The Two Parts bound in one large octavo 
volume. Price $6.00 

Part Two. — Practical and Analytical. Bound Separately, for the Special Con- 
venience of Students. Large 8vo. Cloth. Price $2.50 

MAC MUNN, THE SPECTROSCOPE. 

The Spectroscope in Medicine. By Chas. A. Mac Munn, m.d. With 3 
Chromo-lithographic Plates of Physiological and Pathological Spectra, and 13 
Wood Cuts. 8vo. Price $3.00 

" This book is, without question, the best that has yet been published on the subject ; to those not familiar with 
Physiological Spectroscopy it will prove interesting, while to those who are working in this field it is a neces' 
sity."— New York Medical Journal. 



28 PRESLE Y BLAKISTON'S 

It is eminently a book which will teach the Student. — Practitioner. 
It forms one of the most convenient, practical, and concise books yet 
published on the subject. — London Lancet. 

MEADOWS' MANUAL OF OBSTETRICS. 
THE THIED KEVISED AND EHLAKGED EDITION, NOW BEADY. 

WITH ONE HUNDRED AND FORTY-FIVE ILLUSTRATIONS. 

INCLUDING THE SIGNS AND SYMPTOMS OF PREGNANCY, 

Obstetric Operations, Diseases of the Puerperal State, &c, &c. By 
Alfred Meadows, M. D., Physician to the Hospital for Women, to 
the General Lying-in Hospital, &c, &c. Revised and Enlarged Edi- 
tion. With numerous Illustrations. Price $2.00 

In this new edition, . . .not merely is the practical treatment of Labor, and also of the Dis- 
eases and Accidents of Pregnancy, well and clearly taught, but the anatomical machinery 
of parturition is more effectively explained than in any other treatise that we remember ; 
besides this, the book is honorably distinguished among manuals of Midwifery by the ful- 
ness with which it goes into the subject of the structure and development of the ovum. On 
all questions of treatment, whether by medicines, by hygienic regimen, or by mechanical of 
operative appliances, this treatise is as satisfactory as a work of manual size could be ; students 
and practitioners can hardly do better than adopt it as their vade-mecum. — The Practitioner. 

Upwards of ninety new engravings have been inserted in this edition, and, with a view to 
facilitate reference, the author has furnished it with a very full and complete table of contents 
and index. We can cordially recommend this manual as accurate and practical, and as con- 
taining in a small compass a large amount of the kind of information suitable alike to the 
student and practitioner. — London Lancet. 

It is concise, well arranged, and remarkably complete, as a guide to the student during his 
lecture term ; and as a ready reference to the Physician, no work of similar character equals 
it in value. — Buffalo Medical Journal. 

The systematic arrangement of subjects, and the concise, practical style in which it is 
written, make the work especially valuable as a student's manual, while a very full table 
of contents and index renders it easily accessible as a work of reference. — Chicago Medical 
Examiner. 

There can be no doubt that this manual will be generally accepted as a brief, convenient, 
and compendious guide to the study and practice of the Obstetric Art. — Richmond and 
Louisville Medical Journal. 

We cannot but feel that every teacher of obstetrics has good cause to congratulate himself 
on being able to put in the hands of the student a book which contains so much valuable 
and reliable information in so condensed a form. — Philadelphia Medical Times. 

It is concisely and clearly written, and the information is on the whole on a level with the 
most recent knowledge of the day. — British and Foreign Medical Review. 

A work which embodies a larger amount of practical information than any other book on 
the subject. — Pacific Medical and Surgical Journal. 

It is with great gratification that we are enabled to class Dr. Meadows' Manual as a rare 
exception, and to pronounce it an accurate, practical, and creditable work, and to unhesi- 
tatingly recommend it to both student and practitioner. — American Journal of Obstetrics. 

It is a book of decided merit : every page teems with sound, practical common sense, advice 
and suggestions. — Kansas City Medical Journal. 



PUB LIC A TIONS. 



39 



MENDENHALL, VADE MECUM. 

The Medical Student's Vade Mecum. A Compend of Anatomy, Physiology, 
Chemistry, The Practice of Medicine, Surgery, Obstetrics, etc. By George 
Mendenhall, m.d. Eleventh Edition. 224 Illustrations. 8vo. Price $2.00 

MEIGS AND PEPPER, DISEASES OF CHILDREN. 

A Practical Treatise on the Diseases of Children. By J. Forsyth Meigs, m.d., 
Fellow of the College of Physicians of Philadelphia, etc., etc., and William 
Pepper, m.d., Physician to the Philadelphia Hospital, Provost University of 
Pennsylvania. Seventh Edition, thoroughly Revised and Enlarged. A Royal 
Octavo Volume of over 1000 pages. Price, Cloth, $6.00; Leather, $7.00 

" With the recent additions it may safely be pronounced one of the best and most comprehensive works on Dis- 
eases of Children." — New York Medical Journal. 

" Must be regarded as the most complete work on Diseases of Children in our language." — Edinburgh Medical 
Journal. 

" We have seldom met with a text-book so complete, so just and so readable as the one before us." — American 
Journal of Obstetrics. 

MATHIAS, LEGISLATIVE MANUAL. 

A Rule for Conducting Business in Meetings of Societies, Legislative Bodies, 
Town and Ward Meetings, etc. By Benj. Mathias, a.m. Sixteenth Edition. 
i6mo. Price .50 

MORTON, REFRACTION OF EYE. 

The Refraction of the Eye. Its Diagnosis and the Correction of its Enors. 
With Chapter on Keratoscopy. By A. Stanford Morton, m.b., f.r.c.s. i2*mo. 

Price $1.00 

" The author has not only given very thorough rules for the objective and subjective examinations of the eye in 
the various conditions of refraction which present themselves, but has entered into an explanation of the phenom- 
ena observed, which is at once scientific and elementary." — Edinburgh Medical Journal. 

MEARS, PRACTICAL SURGERY. 

Practical Surgery. Including: Part 1. — Surgical Dressings; Part 11. — Band- 
aging ; Part in. — Ligations ; Part iv. — Amputations. With 227 Illustrations. 
By J. Ewing Mears, m.d., Demonstrator of Surgery in Jefferson Medical Col- 
lege, and Professor of Anatomy and Clinical Surgery in the Pennsylvania Col- 
lege of Dental Surgery. i2mo. Price $2.00 



" Professor Mears has written a convenient and use- 
ful book for students. We can most cordially endorse 
it as fulfilling well the promise made in its modest pre- 
face." — Cincinnati Lancet and Clinic. 



"It contains a great deal of information upon the 
subjects of which it treats, in a convenient and con- 
densed form. Each division is well illustrated, thereby 
rendering the text doubly clear." — New York Medical 
Record. 



OLDBERG, PRESCRIPTION BOOK. 

Three Hundred Prescriptions, Selected Chiefly from the Best Collections of 
Formulas used in Hospital and Out-patient-practice, with a Dose Table, and a 
Complete Account of the Metric System. By Oscar Oldberg, phar. d., Late 
Medical Purveyor, United States Marine Hospital Service ; Professor of Materia 
Medica, National College of Pharmacy, Washington, D. C. ; Member of the 
American Pharmaceutical Association, and of the Sixth Decennial Committee 
of Revision and Publication of the Pharmacopoeia of the United States. 
i2mo. Price $1.50 

The prescriptions given in this work are selected from the Pharmacopoeias and 
formularies of the great Hospitals of New York, Philadelphia, Boston and London, 
or contributed from the practice of medical officers of the United States Service. The 
Dose Table includes nearly all of the remedies that have a place in the current 

Materia Medica. 



30 PRESLE Y BLAKISTON'S 

BY SAME AUTHOR. 

THE UNOFFICIAL PHARMACOPOEIA. 

Comprising over 700 Popular and Useful Preparations, not Official in the 
United States, of the various Elixirs, Fluid Extracts, Mixtures, Syrups, Tinct- 
ures, Ointments, Wines, etc, etc., in constant demand throughout the country. 
Thick i2mo. 503 pp. Half Morocco. Price $3.50 

Sold by Subscription. 
j^r-lT Will Prove a Useful Supplement to the Pharmacopoeia of the 
United States ; the aim has been to make it as complete as practicable. The form- 
ulae can, with a minimum of labor, be used with any system of weights and meas- 
ures. The virtual adoption of the metric system in the forthcoming Pharmacopoeia 
of the United States will account for the preference given. to that system in this vol- 
ume, which, however, does not prevent the ready use of the book with apothecaries' 
weights and measures. An extended account of the metric system has been given, 
accompanied by full tables of equivalents. The sources from which the formulae 
have been gathered are believed to be the best. They include the Pharmacopoeias 
of England, Germany, France and Sweden. The book is practically equivalent to 
the possession of these various Pharmacopoeias, and the formulae were selected with 
reference to their popularity, usefulness, and interesting character. 

" This volume is one of the most practical and valuable contributions to Pharmaceutical work of recent publica- 
tion. It has received high commendation from many of our best pharmacists "—Lazell, Marsh £r» Gardiner, 
Wholesale Druggists, New York City. 

OTT, ACTION OF MEDICINES. 

The Action of Medicines. By Isaac Ott, m.d., late Demonstrator of Experi- 
mental Physiology in the University of Pennsylvania. With 22 Illustrations. 
8vo. Price $2.00 

" This work is the only one in the English language which can offer, with any degree of completeness, that assist- 
ance and instruction so essential to the correct and successful study of pharmacology. Filling, as it does, this gap 
in medical literature, we have a work which cannot fail to be of the greatest value to students. 

" From the pen of a man himself no novice in the subject of which he treats, it bears upon it the impress of relia- 
bility, due to the author's own experience, a virtue too often wanting in mere compilations of the works of oth- 
ers." — American Journal of Medical Sciences. 

PAGET, SURGICAL PATHOLOGY. 

Lectures on Surgical Pathology, Delivered at the Royal College of Surgeons. 
By James Paget, f.r.s. Third Edition. Edited by William Turner, m.d. 
With Numerous Illustrations. 8vo. Price, Cloth, $7.00; Leather, $8.00 

PARKES, PRACTICAL HYGIENE. Fifth Edition. 

A Manual of Practical Hygiene. By Edward A. Parkes, m.d. The Fifth, 
Revised and Enlarged Edition. With Many Illustrations. 8vo. Price $6.00 

"Altogether it is the most complete work on Hygiene which we have seen." — Neiv York Medical Record. 

"We find that it never fails to throw light on any hygienic question which may be proposed." — Boston Medi- 
cal and Surgical Journal. 

"We commend the book heartily to all needing instruction (and who does not), in Hygiene " — Chicago Medi- 
cal Journal. 

PIESSE, THE MANUFACTURE OF PERFUMERY. Fourth 
Edition. 

The Art of Perfumery; or the Methods of Obtaining the Odors of Plants, and 
Instruction for the Manufacture of Perfumery, Dentifrices, Soap, Scented Pow- 
ders, Odorous Vinegars and Salts, Snuff, Cosmetics, etc., etc. By G. W. Septi- 
mus Piesse. Fourth Edition. Enlarged. 366 Illustrations. 8vo. Cloth. 

Price $5.50 



"An excellent book." — Commercial Advertiser. 
" It is the best book on Perfumery yet published." — 
Scientific American. 



" Exceedingly useful to druggists and perfumers." — 
Journal of Chemistry. 

" Is in the fullest sense, comprehensive." — Medical 
Record. 



PUB LIC A TIONS. 



PENNSYLVANIA HOSPITAL REPORTS. 

Edited by a Committee of the Hospital Staff. J. M. DaCosta, m.d., and 
William Hunt, m.d. Vols. I and 2, containing Original Articles by former 
and present Members of the Staff. With Lithographic and other Illustrations. 
8vo. Price, per volume, $2.00 

These volumes consist of papers of a practical character, based chiefly on obser- 
vations made at the Hospital, but containing the further experience of the Members 
of the Staff. In issuing the second volume the Editors express their acknowledg- 
ments for the very favorable reception of the first by the profession and press of 
this country and Europe. 

PEREIRA, PRESCRIPTION BOOK. Sixteenth Edition. 

Physician's Prescription Book. Containing Lists of Terms, Phrases, Con- 
tractions and Abbreviations used in Prescriptions, Explanatory Notes, Gram- 
matical Construction of Prescriptions, Rules for the Pronunciation of Pharma- 
ceutical Terms. By Jonathan Pereira, m.d., f.r.s. Sixteenth Edition. 
Price, Cloth, $1.00; Leather, with tucks and pocket, $1.25 

PIGGOTT, ON COPPER. 

Copper Mining and Copper Ore. With a full Description of the Principal 
Copper Mines of the United States, the Art of Mining, etc. By A. Snowden 
Piggott. i2mo. Price # 1. 00 

PRINCE, ORTHOPEDIC SURGERY. 

Plastic and Orthopedic Surgery. By David Prince, m.d. . Containing a 
Report on the Condition of, and Advance made in, Plastic and Orthopedic Sur- 
gery, etc., etc., and Numerous Illustrations. 8vo. Price $4.50 

PHYSICIAN'S VISITING LIST, PUBLISHED ANNUALLY. 

thirty-first year of its publication, 
sizes and prices. 

. pencil, - $1.00 

- 1.25 

- - - - 1.50 
" - 2.00 

" - 2.50 

" .... 3.00 

INTERLEAVED EDITION. 

For 25 Patients weekly, interleaved, tucks, pockets, etc., - 1.25 

The Visiting List contains a New Table of Poisons and their Antidotes. The 
Metric or French Decimal System of Weights and Measures. Posological Tables, 
showing the relation of our present system of Apothecaries' Weights and Measures 
to that of the Metric System, giving the Doses in both. 

This last is a most valuable addition, and will materially aid the Physician. So 
many writers now use the metric system, especially in foreign books and journals, 
that one not familiar with it is constantly confused, and in many cases unable to 
understand the measurements or doses. 



For 25 

75 
100 


Patients 
<< 


weekly. 

< < 

«< 


Tucks, pockets, 
<( << 

it << 

<( 1 < 


5o 


«« 


" 2 vols. 


f Jan. to June ) 
{ July to Dec. j 


100 


<< 


" 2 VOls. 


J Jan. to June I 
{ July to Dec. j 



" It is certainly the most popular Visiting List ex- 
tant." — New York Medical Journal. 

" Its compact size, convenience of arrangement, dur- 
ability, and neatness of manufacture have everywhere 
obtained for it a preference." — Canada Lancet. 



" The book is convenient in form, not too bulky, and 
in every respect the very best Visiting List published." 
— Canada Medical and Surgical Jjurnal. 

"This standard Visiting List, for completeness, com- 
pactness, and simplicity of arrangement, is excelled by 
none in the market." — New York Medical Record. 



32 PRESLEY BL AKISTON 'S 

POWER, HOLMES, ANSTIE AND BARNES (Drs.). 

Reports on the Progress of Medicine, Surgery, Physiology, Midwifery Dis- 
eases of Women and Children, Materia Medica, Medical Jurisprudence Ophthal- 
mology, etc., etc. Reported for the New Sydenham Society. 8vo. Price #2.00 

PURCELL, ON CANCER. 

Cancer. Its Allies and other Tumors, with Specia Reference to their Medi- 
cal and Surgical Treatment. By F. Albert Purcell, m.d., m.r.c.s. Surgeon 
to the Cancer Hospital, Brompton, England. 8vo. Price $3.75 

RADCLIFFE, ON EPILEPSY. 

On Epilepsy, Pain, Paralysis, and other Disorders of the Nervous System. 
By Charles Bland Radcliffe, m.d. Illustrated. i2mo. Price $1.50 

" To no authority can the medical inquirer turn for an analysis of the phenomena of epilepsy with more satisfac- 
tion than to the admirable essay of Dr. Radcliffe."— A merican Journal Medical Sciences. 

ROBERTS, MANUAL OF MIDWIFERY. 

The Student's Guide to the Practice of Midwifery. By D. Lloyd Roberts 
m.d., f.r.c.p., Physician to St. Mary's Hospital, Manchester, etc., etc. Second 
Edition. With 95 Illustrations. i2mo. Price $2.00 

The present edition has been very thoroughly re- 
vised, some chapters having been entirely re-written. 
For its size, it forms a remarkably complete compendi- 
urn of the subject, and can hardly be surpassed in the 
simplicity and clearness of its explanations."— Obstet- 
rical Journal 0/ Great Britain and Ireland. 



"As an obstetrical manual, we think that of Dr. Rob 
erts one of the best now offered to the Profession, as it 
comes with authority, and he possesses the ability to 
condense, and at the same time present a subject clear- 
ly." — American Journal of Medical Scietice. 

"Concise, clear, and practical." — Medital Press 
and Circular. 



REYNOLDS, ELECTRICITY. 

Lectures on the Clinical Uses of Electricity. By J. Russell Reynolds, m.d., 
f.r.s. Second Edition. i2mo. Price $1.00 

" It is thoroughly reliable as a guide, very concise, and will be found exceedingly useful to the general practi- 
tioner." — Canada Lancet. 

RICHARDSON, MECHANICAL DENTISTRY. Third Edi- 
tion. 

A Practical Treatise on Mechanical Dentistry. By Joseph Richardson, d.d.s. 
Third Edition. With 185 Illustrations. 8vo. Price, Cloth, $4.00; Leather, $4.75 

" Taken as a whole, Professor Richardson's work is a valuable contribution to the dental art, and is beyond all 
question the best treatise extant upon the general subject of Mechanical Dentistry." — Dental Cosmos. 

RIGBY AND MEADOWS, OBSTETRIC MEMORANDA. 

Dr. Rigby's Obstetric Memoranda. Fourth Edition. Revised. By Alfred 
Meadows, m.d. 32mo. Price .50 

RINDFLEISCH, PATHOLOGICAL HISTOLOGY. 

A Text-Book of Pathological Histology. By Dr. Edward Rindfleisch. 
Translated by Drs. Wm. C. Kolman and F. T. Miller. 208 Illustrations. 
8vo. Price, Cloth, $5.00; Leather, $6.00 

Recommended as a Text-Book at the University of Pennsylvania and other Med- 
ical Schools. 

" To be up with the times our Pathologists must make themselves familiar with the thorough, clear and almost 
exhaustive teachings of Professor Rindfleisch." — Ohio Medical and Surgical Reporter. 

" In conclusion we cordially recommend it as the best treatise on the subject." — American Journal of Medi- 
cal Science. 

RYAN, ON MARRIAGE. 

The Philosophy of Marriage. In its Social, Moral and Physical Relations, 
and Diseases of the Urinary Organs. By Michael Ryan, m.d. Member of 
the Royal College of Physicians, London. i2mo. Price $1.00 



PUB LIC A TIONS. 33 



ROBERTS' PRACTICE OF MEDICINE 

A New Enlarged Edition, 

JUST READY. 

Uniformly commended by the Profession and the Press. 

A HAND-BOOK OF THE THEORY AND PRACTICE OF MEDI- 
CINE. By Frederick T. Roberts, M.D., M.R.C.P., Assistant Pro- 
fessor and Teacher of Clinical Medicine in University College Hospital, 
Assistant Physician in Brampton Consumptive Hospital, &c, &c. 
Third Edition. Octavo. Price, in cloth .... $5.00 

leather .... 6.00 
The Publishers are in receipt of numerous letters from Professors in the various Med- 
ical Schools, uniformly commending this book ; whilst the following extracts from the 
Medical Press, both English and American, fully attest its superiority and great value 
not only to the student, but also to the busy practitioner. 

This is a good book, yea, a very good book. It is not so full in its Pathology as " Aitken," 
so charming in its composition as " Watson," nor so decisive in its treatment as " Tanner; " 
but it is more compendious than any of them, and therefore more useful. We know of no 
other work in the English language, or in any other, for that matter, which competes with 
this one. — Edinburgh Medical Journal. 

We have much pleasure in expressing our sense of the author's conscientious anxiety to 
make his work a faithful representation of modern medical beliefs and practice. In this he 
has succeeded in a degree that will earn the gratitude of very many students .and practition- 
ers: it is a remarkable evidence of industry, experience, and research. — Practitioner. 

That Dr. Roberts's book is admirably fitted to supply the want of a good hand-book of 
medicine, so much felt by every medical student, does not admit of a question. — Students' 
Journal and Hospital Gazette. 

Dr. Roberts has accomplished his task in a satisfactory manner, and has produced a work 
mainly intended for students that will be cordially welcomed by them ; most of the observa- 
tions on treatment are carefully written and worthy of attentive study; the arrangement is 
good, and the style clear and simple. — London Lancet. 

It contains a vast deal of capital instruction for the student, much valuable matter in it to 
commend, and merit enough to insure for it a rapid sale. — London Medical Times and Gazette. 

There are great excellencies in this book, which will make it a favorite both with the 
accurate student and busy practitioner. The author has had ample experience. — Richmond 
and, Louisville Journal. 

We confess ourselves most favorably impressed with this work. The author has performed 
his task most creditably, and we cordially recommend the book to our readers. — Canada 
Medical and Surgical Journal. 

A careful reading of the book has led us to believe that the author has written a work 
more nearly up to the times than any that we have seen ; to the student, it will be a gift of 
priceless value. — Detroit Review of Medicine. 

Our opinion of it is one of almost unqualified praise. The style is clear, and the amount of 
useful and, indeed, indispensable information which it contains is marvellous. We heartily 
recommend it to students, teachers, and practitioners. — Boston Med. and Surgical Journal. 

It is of a much higher order than the usual compilations and abstracts placed in the hands 
of students. It embraces many suggestions and hints from a carefully compiled hospital 
experience ; the style is clear and concise, and the plan of the work very judicious. — Medical 
and Surgical Reporter. 

It is unsurpassed by any work that has fallen into our hands as a compendium for students 
preparing for examination. It is thoroughly practical and fully up to the times. — The Clinic. 

We find it an admirable book. Indeed, we know of no hand-book on the subject just now 
to be preferred to it. We particularly commend it to students about to enter upon the 
practice of their profession. — St. Louis Medical and Surgical Journal. 

If there is a book in the whole of medical literature in which so much is said in so 
few words, it has never come within our reach. So clear, terse, and pointed is the style ; 
so accurate the diction, and so varied the matter of this book, that it is almost a dictionary 
of practical medicine. — Clucago Medical Journal. 



34 PRESLEY BLAKISTON'S 



SANDERSON AND FOSTER, THE PHYSIOLOGICAL LA- 
BORATORY. 

A Hand-book of the Physiological Laboratory. Being Practical Exercises for 
Students in Physiology and Histology. By J. Burdon Sanderson, m.d., E. 
Klein, m.d., Michael Foster, m.d., f.r.s., and T. Lauder Brunton, m.d. 
With over 350 Illustrations and Appropriate Letter-press Explanations and Ref- 
erences. 

Price, Two Volumes, Text and Plates, separate, - $7 .00 

" One *■' " " bound together, Cloth, 6.00 

Leather, 7.00 
Adopted as a Text-book at Yale College, and used at other Medical Schools in 
America and England. 



" Recognizing the fact that Physiology is emphatic- 
ally an experimental science, it furnishes minute in- 
structions for performing a great variety of exper- 
iments. A student could scarcely desire a better guide." 
— Boston Medical and Surgical Journal. 



"We confidently recommend it to the attention of all 
who are interested in the wide and fertile field of Phy- 
siological research." — New York Medical Journal. 

" This is a most superb book, and fills a hiatus which 
every physiological student has lamented." — Chicago 
Medical Journal. 

SANDERSON, PHYSIOLOGY. Second Edition. 

A Syllabus of a Course of Lectures on Physiology. By J. Burdon Sander- 
son, m.d. For the Use of Students. Second Edition. 8vo. Price $1.50 

SANSOM, PHYSICAL DIAGNOSIS. Third Edition just ready. 

The Physical Diagnosis of Diseases of the Heart. Including the Use of the 
Sphygmograph and Cardiograph. By Arthur Ernest Sansom, m.d. Third 
Edition. Revised and Enlarged. With Illustrations. i2mo. Price $2.00 

" Dr. Sansom is favorably known, and the little work he here presents reflects creditably on his skill in pre- 
senting with singular clearness, one of the most difficult branches of diagnosis." — Philadelphia Medical and Sur- 
gical Reporter. 

BY SAME AUTHOR. 

ON CHLOROFORM. 

Chloroform. Its Action and Administration. i2mo. Price $1.50 

SMITH, MANUAL OF GYNECOLOGY. 

Practical Gynaecology. A Hand-book of the Diseases of Women. By Hey- 
wood Smith, m.d. Physician to the Hospital for Women and to the British 
Lying-in Hospital. With Engravings. Price $1.5 

The object of the author has been to present the busy practitioner with a book 
systematically arranged, burdened with no discussions on vexed questions of pathol- 
ogy, and giving at a glance the salient points of diagnosis and treatment with clear- 
ness and brevity. 

Contents. — Chapter 1. On the Means of Diagnosis : On Touch — immediate and intermediate. On Sight 
— immediate and intermediate. On Hearing. — immediate and intermediate. 2. General Diseases. 3. Local 
Diseases — Diseases of the Ovary. 4. Diseases of the Oviduct. 5. Diseases of the Broad Ligament. 6. Diseases 
of the Uterus (unimpregnated). 7. Diseases of the Vagina. 8. Diseases of the Vulva. 9. Diseases of the Mam- 
ma. 10. Functional Diseases, n. Diseases connected with Pregnancy. 12. Diseases connected with Parturi- 
tion. 13. Diseases consequent on Parturition. Appendix of Remedies. 

BY SAME AUTHOR. 

DYSMENORRHEA. Just Issued. 

Its Pathology and Treatment. i2mo. Price $2.50 

SMITH, RINGWORM. 

The Diagnosis and Treatment of Ringworm. By Alder Smith, f.r.c.s. 
With Illustrations. i2mo. Price $1.00 

SMITH, ON NURSING. 

The Efficient Training of Nurses for Hospital and Private Practice. By Wil- 
liam Robert Smith. Illustrated. i2mo. Price #2.00 



PUBLICATIONS. 35 



SMITH, ON CHILDREN. 

Clinical Studies of Diseases in Children. By Eustace Smith, m.d. i2mo. 

Price $2.50 

MEDICAL HERESIES, HISTORICALLY CONSIDERED. 

A Series of Critical Essays on the Origin and Evolution of Sectarian Medi- 
cine, embracing a Special Sketch and Review of Homoeopathy, Past and Pres- 
ent. By Gonzalvo C. Smythe, a.m., m.d. Professor of the Principles and 
Practice of Medicine, College of Physicians and Surgeons, Indianapolis, Indi- 
ana. i2mo. Cloth. Price $1.25 



" This book gives, in a small compass, an excellent 
history of medicine, from its earliest day to the present 
time." — Buffalo Medical and Surgical Journal. 

" Cannot fail to be of interest, not only to- the medi- 
cal profession, but to the general reader." — Baltimore 
Gazette. 

" The work is pleasantly written, in an easy, familiar 
style, and has cost the writer much literary research." 
— New York Medical Journal. 



" Students and others interested in the subject of 
medicine will find a digest of the entire controversy 
(between the various schools of medicine) presented in 
this volume." — Journal of Edztcati^n. 

" Professor Smythe has succeeded in writing a brief, 
clear, and interesting sketch of the evolution of medical 
eccentricities, and of modern homoeopathy, its facts and 
fallacies." — Philadelphia Medical Times. 



SAVAGE, FEMALE PELVIC ORGANS. Author's Edition. 

The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic 
Organs. In a Series of Colored Plates taken from Nature, with Commentaries, 
Notes and Cases. By Henry Savage, m.d., f.r.c.s. New Edition. Issued by 
arrangement with the Author, from the original Plates. Quarto. {Preparing. 

SAVORY & MOORE, DOMESTIC MEDICINE. 

A Condensed Compend of Domestic Medicine, and Companion to the Medi- 
cine Chest. By Drs. Savory and Moore. Illustrated. i6mo. Price .50 

SCHULTZE, OBSTETRICAL PLATES. 

Obstetrical Diagrams. Life Size. By Prof. B. S. Schultze, m.d., of Berlin. 
Twenty in the Set. Colored. 

Price, in Sheets, $15.00; Mounted on Rollers $25.00 

SCANZONI, DISEASES OF WOMEN. 

A Practical Treatise on the Diseases of the Sexual Organs of Women. By 
Dr. F. W. Von Scanzoni. Translated by A. K. Gardiner, m.d. 8vo. 

Price $5.00 

SIEVEKING, LIFE ASSURANCE. 

The Medical Adviser in Life Assurance. By E. H. Sieveking, m.d. i2mo. 

Price $2.00 

SHEPPARD, ON MADNESS. 

Madness, in its Medical, Social and Legal Aspects. A Series of Lectures de- 
livered at King's Medical College, London. By Edgar Sheppard, m.d. 8vo. 

Price $2.25 

STOCKEN, DENTAL MATERIA MEDICA. Second Edition. 

The Elements of Dental Materia Medicaand Therapeutics with Pharmacopoeia. 
By James Stocken, d.d.s. Second Edition. i2tno. Price $2.25 

The first edition of this book was disposed of in a little less than four months. In 
making this revision the author has endeavored to make it still more useful by the 
addition of considerable new matter. 

SUTTON, VOLUMETRIC ANALYSIS. Fourth Edition. 

A Systematic Handbook of Volumetric Analysis, or the Quantitative Estima- 
tion of Chemical Substances by Measure, Applied to Liquids, Solids and Gases. 
By Francis Sutton, f.c.s. Fourth Edition. Revised and Enlarged, with Illus- 
trations. 8vo. [Preparing. 



36 PRESLE Y BLAKISTON'S 

SEWELL, DENTAL ANATOMY AND SURGERY. 

A Manual of Dental Anatomy and Surgery, Including the Extraction of Teeth. 
By H. E. Sewell, d.d.s., m.d. With yj Illustrations. i2mo. Price $1.50 

" A valuable book for the general Practitioner who " It will be found useful to the general Practitioner in 

fe in want of a practical manual relating especially to the management of many incidental affections connected 
diseases of the teeth." — Medical Brief. with the teeth and mouth, which cannot always be 

handed over to the specialist."— Pacific Med. Journal. 

STILLE, ON MENINGITIS. 

Epidemic Meningitis, or Cerebro-spinal Meningitis. By Alfred Stille, m.d., 
Professor of Practice at the University of Pennsylvania. 8vo. Price $2.00 

" The name of the author is a sufficient guarantee that this monograph is elegant in style, exhaustive of its sub- 
ject and rich with practical suggestions."— Philadelphia Medical and Surgical Reporter. 

STOKES, DISEASES OF THE HEART. 

The Diseases of the Heart and Aorta. By William Stokes, m.d. Thick 
8vo. Price $3.00 

SWAIN, SURGICAL EMERGENCIES. 

Surgical Emergencies : Concise Descriptions of the Various Accidents and 
Emergencies, with Directions for their Treatment. By Wm. Paul Swain, f.r. 
C.s. Eighty-two Illustrations. i2mo. • Price $2.00 

Contents.— Chapter I. Injuries to the Head. II. Injuries to the Eye. III. Injuries to the Mouth, 
Pharynx, (Esophagus, and Larynx. IV. The Chest. V. The Upper Extremity. VI. The Abdomen. VII. 
The Pelvis. VIII. The Lower Extremity. IX. Emergencies connected with Parturition. X. Poisoning. 
XI. Antiseptic Treatment. XII. Apparatus and Dressing. 

" Many surgeons will thank Dr. Swain for the trouble he has taken to put them easily in possession of this re- 
fresher of half forgotten knowledge. — The Practitioner. 

SWERINGEN, PHARMACEUTICAL LEXICON. 

A Pharmaceutical Lexicon or Dictionary of Pharmaceutical Science. Contain- 
ing explanations of the various subjects and terms of Pharmacy, with appropriate 
selections from the Collateral Sciences. Formulae for Officinal, Empirical, and 
Dietetic Preparations, etc., etc. By Hiram. V. Sweringen, m.d. 8vo. 

Price, Cloth, $3.00; Leather, $4.00 

" It is worthy of a welcome, and sure of a ready recognition of its merits." — London Pharmaceutical Journal. 
" It will prove of great service to the pharmaceutical student, apprentice, pharmacist, druggist and physician, as 
a book of ready reference and as an aid to the study of scientific works." — American Journal of Pharmacy. 

THOMPSON, LITHOTOMY AND LITHOTRITY. 

Practical Lithotomy and Lithotrity ; or, an Inquiry into the best Modes of 
Removing Stone from the Bladder. By Sir Henry Thompson, f.r.c.s., Emer- 
itus Professor of Clinical Surgery in University College. Third Edition. 8vo. 
With 87 Engravings. Price $3.50 

"The chapters of most intei-est are those in which Bigelow's operation is discussed, and the final one, in 
which is a record of 500 operations for stone in cases of male adults under the author's care. Such a table has 
newer'before been compiled by any surgeon." — Lancet. 

BY SAME AUTHOR. 

URINARY ORGANS. 

Diseases of the Urinary Organs. Clinical Lectures. Fifth Londoa Edition. 
8vo. With 2 Plates and 71 Engravings. Price $3.50 

ON THE PROSTATE. 

Diseases of the Prostate. Their Pathology and Treatment. Fourth London 
Edition. 8vo. With numerous Plates. Price $4.00 

CALCULOUS DISEASES. 

The Preventive Treatment of Calculous Disease, and the Use of Solvent 
Remedies. Second Edition. i6mo. Price $1.00 

"Catholic in-his investigation of the fruit of the labor of others, cautious in all his deductions, rejecting all spe- 
cious theories in the effort to obtain practically useful results, as clever with his pen as he is with the sound or 
lithotrke,' one. can scarcely wonder that he is'*esteemed the master that he is." — American Journal of Medico} 
Science. 



PUB LIC A TIONS. 37 



TROUSSEAU'S CLINICAL MEDICINE. 

COMPLETE. 
In Two Large Koyal Octavo Volumes. 

EMBEACING ALL THE LECTURES CONTAINED IN THE FIVE 

VOLUME EDITION AS ISSUED BY THE 

SYDENHAM SOCIETY. 

Price, handsomely bound in cloth % 8.00 

leather 10.00 

Lectures on Clinical Medicine. 

Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clin- 
ical Medicine to the Faculty of Medicine, Paris, &c, &c. Translated 
from the Third Revised and Enlarged Edition by P. Victor Bazire, 
M. D., London and Paris ; and John Hose Cormack, M. D., Edinburgh, 
F. R. S., &c. With a full Index, Table of Contents, &c. 

Trousseau's Lectures have attained a reputation both in England and in this country far 
greater than any work of a similar character heretofore written, and, notwithstanding but few 
medical men could afford to purchase the expensive edition issued by the Sydenham Soci- 
ety, it has had an extensive sale. In order, however, to bring the work within the reach of all 
the profession, the publishers now issue this edition, containing all the lectures as contained 
in the five-volume edition, at one-half the price. Below are a few only of the many favora- 
ble opinions expressed of the woik : 

" It treats of diseases of daily occurrence and of the most vital interest to the practitioner. 
And we should think any medical library absurdly incomplete now which did not have 
alongside of Watson, Graves, and Tanner, the ' Clinical Medicine ' of Trousseau. 

" The work is full of the results of the richest natural observation, and is the production 
of one who was enlightened enough to combine with new methods of investigation the vigor- 
ous and independent ideas of the old physicians whom he so eloquently magnifies. It is an 
extremely rich and valuable addition to the library of p Uysicians and practitioners generally." 

— London Lancet. 

" This book furnishes an example of the best kind c f clinical teaching. It deserves to be 
popularized. We scarcely know of any work better fitted for presentation to a young man 
when entering upon the practical work of his life. Tie delineation of the recorded cases is 
graphic, and their narration devoid of that prolixity wnich, desirable as it is for purposes of 
extended analysis, is highly undesirable when the object is to point to a practical lesson."— 
London Medical Times and Gazette. 

" The publication of Trousseau's Lectures furnishes medical men with one of the best 
practical treatises on disease as seen at the bedside. The conversational style adopted by 
the author lends animation to the work, and the translator deserves credit for having so well 
preserved the easy and ready style of the original." — British and Foreign Medico- Chirur 
gical Review. 

" The great reputation of Prof. Trousseau as a practitioner and teacher of Medicine in all 
its branches, renders the present appearance of his Clinical Lectures particularly welcome." 

— Medical Press and Circular. 

l ' A cVver translation of Prof. Trousseau's admirable and exhaustive work, the best boo* 
M reference upon the Practice of Medicine." — Indian Medical Gazette. 



48 PRESLEY BLAKISTON'S . 

TILT, THE CHANGE OF LIFE IN WOMEN. 

The Change of Life in Health and Disease. A Practical Treatise on the 
Diseases Incidental to Women at the Decline of Life. By Edward John Tilt, 
m.d. Third London Edition. 8vo. Price $3.00 

BY SAME AUTHOR. 

UTERINE THERAPEUTICS AND DISEASES OF WOMEN. 

A Hand-book of Diseases of Women and Uterine Therapeutics. Fourth 
London Edition. i2mo. Price $3.50 

TOMES, DENTAL ANATOMY. New Edition. 

A Manual of Dental Anatomy, Human and Comparative. By C. S. Tomes, 
d.d.s. With 179 Illustrations. Second Edition. i2mo. [Preparing.] 

TOMES, DENTAL SURGERY. 

A System of Dental Surgery. By John Tomes, f.r.s. The Second Edition, 
Revised and Enlarged. By C. S. Tomes, d.d.s. With 263 Illustrations. i2mo. 

Price $5.00 

" We rejoice that such books as these (Dr. Tomes' Works) are demanded by the profession, and that the men 
to write them are furnished by the profession." — Dental Cosmos. 

TAFT, OPERATIVE DENTISTRY. Third Edition. 

A Practical Treatise on Operative Dentistry. By Jonathan Taft, d.d.s. 
Third Revised and Enlarged Edition. Over 100 Illustrations. 8vo. 

Price, Cloth, $4.25 ; Leather, 5.00 

" It is a thorough and complete treatise on the Art 
of Practical Dentistry." — London Medical Times and 
Gazette. 



"All the important operations, in all their modifica- 
tions, are clearly discussed by the author, and the 
work is highly practical throughout." — Dental Regis- 
ter. 



TANNER, INDEX OF DISEASES. Second Edition. 

An Index of Diseases and their Treatment. By Thos. Hawkes Tanner, m.d., 

f.r.c.p. Sixth Edition. Revised and Enlarged. By W. H. Broadbent, m.d. 

With Additions. Appendix of Formulae, etc. 8vo. Price $3.00 

By this useful hand-book the character of any disease may be determined in a 

moment, and the general outline of treatment pursued by the best authorities made 

apparent. 



"This work, like others from the gifted author, has 
already won for itself a reputation." . . . " It is 
in truth what its title indicates." — New York Medical 
Record. 



" Finally, a chapter on the climates, countries, mine- 
ral springs, etc, best adapted to the various classes of 
invalids, makes this work the most complete practi- 
tioner's manual that we have yet seen. — Chicago Medi- 
cal Times. 



BY SAME AUTHOR. 

THE DISEASES OF INFANCY. 

A Practical Treatise on the Diseases of Infancy and Childhood. Third Edi- 
tion. Carefully Revised and much Enlarged. By Alfred Meadows, m.d. 
8vo. Price #3.00 

Recommended as a Text-book at Jefferson Medical College and other schools of 
Medicine. 

"One of the most careful, ornate, and accessible I "We consider the views of the author on the subject 
manuals on the subject." — London Lancet. of therapeutics as rational in the highest degree." — 

j Boston Medical and Surgical yournal. 

MEMORANDA OF POISONS. 

A Memoranda of Poisons and their Antidotes and Tests. Fourth American 
from the Last London Edition. Revised and Enlarged. Price .75 

This most complete Toxicological Manual should be within reach of all physi- 
cians and pharmacists, and as an addition to every family library, would be the 
means of saving life and allaying pain when the delay of sending for a physician 
would prove fatal. 



PUBLICA TIONS. 39 



TIBBETS, MEDICAL, ELECTRICITY. 

A Hand-book of Medical Electricity. Giving full directions for its Applica- 
tion, etc. By Herbert Tibbets, m.d. 64 Illustrations. 8vo. Price $1.50 

TOLAND, PRACTICAL SURGERY. 

Lectures on Practical Surgery. By H. H. Toland, m.d., Professor of Surgery, 
University of California. Second Edition. With Additions and Numerous Illus- 
trations. 8vo. Price, Cloth, $4.50; Leather, $5.00 

TRANSACTIONS OF THE COLLEGE OF PHYSICIANS. 

The Transactions of the College of Physicians of Philadelphia. New Series. 
Vols. 1, II, in, iv and v. 8vo. Price, per volume, $2.50 

TYSON, BRIGHT'S DISEASE AND DIABETES. 

A Treatise on Diabetes and Bright's Disease. With Especial Reference to 
Pathology and Therapeutics. By James Tyson, m.d., Professor of Pathology 
and Morbid Anatomy in the University of Pennsylvania. With Colored Plates 
and many Wood Engravings. 8vo. Price $3.50 



" This volume is the outcome of some fifteen years' 
special study and observation, and will be found to be 
a very well prepared monograph His direc- 
tions are clear and minute. — Med. and Surg. Reporter. 



" The symptoms are clearly defined, and the treat- 
ment is exceedingly well described, so that every one 
reading the book must be profited."— Cincinnati Lan- 
cet and Clinic. 



BY SAME AUTHOR. 

GUIDE TO THE EXAMINATION OF URINE. 

A Practical Guide to the Examination of Urine. For the use of Physicians and 

Students. With Colored Plate, and Numerous Illustrations Engraved on Wood. 

Third Edition. i2mo. • Price $1.50 

Advantage has been taken, in bringing out a new edition of this work, not only to 

correct the previous one, but to make such additions of new Facts and Processes as 

would add to its value without materially increasing its size. 

" Dr. Tyson commences with a short account of the theory of renal secretion, the physical and chemical charac- 
ters of the urine, and the reagents and apparatus used in its analysis. Excellent rules are then given for detecting 
the presence of albumen, sugar, coloring-matters, bile, urea, uric acid, chlorides, phosphates and sulphates ; and 
minute instructions for approximative and quantitative determination of most of those ingredients by volumetric 
analysis are supplied." — Philadelphia Medical Times. 

"We have experienced both pleasure and profit ftom the perusal of this book. It is agreeably written, contains 
much practical information, and is, we believe, a reliable and satisfactory guide to the clinical examination oi 
srine. We can recommend Dr. Tyson's book as one that amply supplies the clinical needs of the physician." — 
Dublin Journal of Medical Science. 

THE CELL DOCTRINE. Second Edition. 

The Cell Doctrine. Its History and Present State. With a Copious Biblio- 
graphy of the subject. Illustrated by a Colored Plate and Wood Cuts. Second 
Edition. 8vo. Price $2.00 

TURNBULL, ARTIFICIAL ANESTHESIA. 

The Advantages and Accidents of Artificial Anaesthesia ; Its Employment in 
the Treatment of Disease ; Modes of Administration ; Considering their Rela- 
tive Risks ; Tests of Purity ; Treatment of Asphyxia ; Spasms of the Glottis ; 
Syncope, etc. By Laurence Turnbull. m.d., ph. g., Aural Surgeon to Jeffer- 
son College Hospital, etc. Second Edition. Revised and Enlarged. With 27 
Illustrations of Various Forms of Inhalers, etc. nmo. Price $1.50 

" Anaesthesia is a subject of great interest and importance to physicians and dentists, and everything that will 
aid them in better understanding the subject is sought with great avidity. This work we regard as the best aid in 
the study of the subject, and it presents the subject up to the present hour." — Dental Register. 

TEALE, DANGERS TO HEALTH. Third Edition. 

A Pictorial Guide to Domestic Sanitary Defects. By T. Pridjin Teale, m.d., 
f.r.c.s. With Colored Plates. 8vo. Price #3.50 



4o__ PRESLEY BLAKI STON'S 

VACHER, CHEMISTRY. 

A Primer of Chemistry, Including Analysis. By Arthur Vacher. i8mo. 

Price .50 

VIRCHOW, POST-MORTEM EXAMINATIONS. Second Edi- 
tion. 

Post-mortem Examinations. A Description and Explanation of the Method 
of Performing them in the Dead House of the Berlin Charite Hospital, with 
especial reference to Medico-legal Practice. By Prof. Virchow. Translated 
by Dr. T. P. Smith. Second Edition. i2mo. With 4 Plates. Price $1.25 

" A most useful manual from the pen of a master. " Its low price and portability make it accessible and 

. . . . For thorough and systematic method in convenient to every surgical registrar and practitioner." 

the performance of post-mortem examinations, there is — British Medical Journal. 

no guide like it." — Lancet. 

WAGSTAFFE, HUMAN OSTEOLOGY. 

The Student's Guide to Human Osteology. By William Warwick Wag- 
staffe, f.r.c.s. With 23 Lithographic Plates of the Bones, Showing Muscle 
Attachments, and 60 Wood Engravings. i2mo. Price $3.00 

WALTON, DISEASES OF THE EYE. Third Edition. 

A Practical Treatise on Diseases of the Eye. By Haynes Walton, m.d. 
Third Edition. Rewritten and Enlarged. With five plain and three colored 
full-page Plates; and many other Illustrations, Test Types, etc. Nearly 1200 
pages. 8vo. Price $9.00 

WARNER, CASE TAKING. 

The Student's Guide to Medical Case Taking. By Francis Warner, m.d., 
m.r.c.p., etc. i2mo. Cloth. Price $1.75 

General Diseases. — Class i. Class 2. Arthritic Diseases. Diseases of the Nervous System. Of the Vas- 
cular System. Of the Respiratory System. Of the Digestive System. Of the Liver. Of the Urinary System. 
Instruction for Case Taking. 

WATERS, DISEASES OF THE CHEST. Second Edition. 

The Diseases of the Chest. Their Clinical History, Pathology and Treat- 
ment. By A. T. H. Waters, m.d., Fellow Royal College of Physicians. With 
Numerous Illustrative Cases and Lithographic Plates. 8vo. Price $4.00 

" The present edition contains new chapters on haemoptysis, hay fever, aortic regurgitation, mitral constriction, 
thoracic aneurism, and the use of chloral in certain diseases of the chest ; other chapters have received additions 
of cases and remarks on treatment. Some characteristic sphygmographic tracings have also been added." — Bos- 
ton Medical and Surgical Journal. 

WEDL, ATLAS OF THE TEETH. 

An Atlas of the Pathology of the Teeth. By Prof. Carl Wedl, of Leipsig. 
16 Full-page Lithographs, containing many figures, some colored. Quarto. 

Price #10.00 

BY SAME AUTHOR. 

DENTAL PATHOLOGY. 

With Special Reference to the Anatomy and Physiology of the Teeth. With 
Notes by Thos. B. Hitchcock, m.d., of Harvard University. 105 Illustra- 
trations. 8vo. Price, Cloth, $3.50; Leather, $4.50 

WHITTAKER, ON THE URINE. 

Student's Primer on the Urine. By J. Travis Whittaker, m.d., Physician to 
Anderson's College Dispensary. With Illustrations Etched on Copper. i6mo. 

Price $1.50 

Physiological Study of Urine — Sensation in Passing. Quantity. Color. Odor. Specific Gravity. History 
and Behavior. Sediment or Deposits. Chemical Study of Urine— Reaction. Albumen. Chlorides. Ammonia. 
Urea. Phosphates. Blood. Sugar. Bile. Microscopical Study of Urine and Urinary Deposits— Amorphous 
Urates. Uric Acid. Triple Phosphates. Phosphate of Lime. Feathery Phosphates. Oxalate of Lime. Urate 
of Soda and of Ammonia. Cystine. Tyrosine. Leucine. Cholesterine. Epithelium. Fat Globules, etc. 

"The plates are possessed of great versimilitude, as well as in other respects admirable." — Med. Times. 

" Neat and concise, and the illustrations are very good testimony of the claim which he makes of the suitability 
of the etching needle for delineation of microscopical appearances." — Boston Med. and Surg. Journal. 



PUB LIC A TIONS. 



4* 



WEST, THE DISEASES OF WOMEN. Fourth Edition. 

Lectures on the Diseases of Women. By Charles West, m.d. Fourth 
London Edition. Revised and in part re-written by the Author. With Numer- 
ous Additions by J. Mathews Duncan, m.d., Obstetric Physician to St. Bar- 
tholomew's Hospital 8vo. Price $5.00 
Drs. West and Duncan are, perhaps, the most celebrated London physicians 
giving attention to the Diseases of Women, and together have made a most com- 
plete work, either for the physician or student. 

WILKES, PATHOLOGICAL ANATOMY. 

Lectures on Pathological Anatomy. By Samuel Wilkes, f.r.s. Second 
Edition. Revised and Enlarged by Walter Moxon, m.d., f.r.s., Physician to 



and Lecturer at Guy's Hospital, London. 8vo. 



Price I5.00 



BY SAME AUTHOR. 



DISEASES OF THE NERVOUS SYSTEM. 

Lectures on Diseases of the Nervous System, Delivered at Guy's Hospital, 
London. New Edition, with Additions, Numerous Illustrative Cases, etc. 8vo. 

[Preparing. 

"A book of great value, embodying as It does the results of the experience and observation of one of the most 
accomplished of the London Hospital Physicians." — American Journal of Medical Science. 

WRIGHT, ON HEADACHES. Ninth Thousand. 

Headaches, their Causes, Nature and Treatment. By Henry G. Wright, 
m.d i2mo. Price .50 

WILSON, ON DRAINAGE. 

Drainage for Health ; or, Easy Lessons in Sanitary Science, with Numerous 
Illustrations. By Joseph Wilson, m.d., Medical Director United States Navy. 
One Vol. Octavo. Price $1.00 



" Easily understood, and briefly and concisely pre- 
sented." — Providence Journal. 

" Will be found of value." — Boston Transcript. 

"Worthy of praise as a popular statement of the 
subject." — Boston Journal of Chemistry. 

" Will be sure to be a harbinger of good in every fam- 
ily whose good fortune it may be to possess a copy." — 
Builder and Wood Worker. 



" Dr. Wilson is favorably known as one of the lead- 
ing American writers on hygiene and public health. 
The book deserves popularity." — Medical and Surgi- 
cal Reporter. 

" Well written and well illustrated. Attention to its 
teachings may save much disease and perhaps many 
lives." — Cincinnati Gazette. 

" Interesting as well as useful." — Philadelphia Led- 
ger. 

BY SAME AUTHOR. 

NAVAL HYGIENE. 

Naval Hygiene, or, Human Health and Means for Preventing Disease. With 
Illustrative Incidents derived from Naval Experience. Illustrated. Second 
Edition. 8vo. Price $3.00 

WILSON, DOMESTIC HYGIENE. 

Health and Healthy Homes. A Guide to Personal and Domestic Hygiene. 
By George Wilson, m.d., Medical Officer of Health. Edited by Jos. G. 
Richardson, m.d., Professor of Hygiene at the University of Pennsylvania. 
314 pages. i2mo. Price $i.oc 

Chapter i. — Introductory, page 17. 11. The Human Body, 33. in. Causes of Disease, 66. iv. Food and 
Diet, 119. v. Cleanliness and Clothing, 169. VI. Exercise, Recreation and Training, 187. vn. Home and Its 
Surroundings, Drainage, Warming, etc., 221. VIII. Infectious Diseases and their Prevention, 269. 

"A most useful, and in every way, acceptable book." — New York Herald. 

" Marked throughout by a sound, scientific spirit, and an absence of all hasty generalizations, sweeping asser- 
tions, and abuse of statistics in support of the writer's particular views. . . . We cannot speak too highly of 
a work which we have read with entire satisfaction." — Medical Times and Gazette. 



BY SAME AUTHOR. 



A HAND-BOOK OF HYGIENE 

And Sanitary Science. With Illustrations. 
Enlarged. 8vo. 



Fourth Edition. 



Revised and 
Price $2.75 



42 PRESLE Y B LA KIS TON'S 

WILSON, HUMAN ANATOMY. Tenth Edition. 

The Anatomist's Vade-Mecum. General and Special. By Prof. Erasmus Wil- 
son. Edited by George Buchanan, Professor of Clinical Surgery in the Uni- 
versity of Glasgow ; and Henry E. Clark, Lecturer on Anatomy at the Royal 
Infirmary School of Medicine, Glasgow. Tenth Edition. With 450 Engravings 
(including 26 Colored Plates). Crown 8vo. Price $6.00 

Recommended as a Text-book at Rush Medical College, Chicago ; Bellevue Hos- 
pital, New York; St. Louis Medical College; Yale and Dartmouth Schools; and 
many other Colleges. 

"The present edition of the 'Anatomist's Vade-mecum,' has been prepared under 
the same editorial control as the Ninth Edition. 

" Numerous additional wood cuts have been introduced, and full-page engravings 
of the bones, which have been drawn and engraved with great care, to secure ac- 
curacy, and to make them not mere anatomical diagrams, but artistic pictures." 

BY SAME AUTHOR. 

HEALTHY SKIN. Eighth Edition. 

A Practical Treatise on the Skin and Hair ; their Preservation and Manage- 
ment. Eighth Edition. i2mo. Paper. Price $1.00 

WILSON, SEA VOYAGES FOR HEALTH. 

The Ocean as a Health Resort. A Hand-book of Practical Information as to 
Sea Voyages, for the Use of Tourists and Invalids. By Wm. S. Wilson, l.r.c.p. 
Lond., m.r.c.s.e. With a Chart showing the Ocean Routes, and Illustrating the 
Physical Geography of the Sea. Crown 8vo. Price $2.50 

Chapter 1. Curative Effects of the Ocean Climate. 2. The Various Health Voyages. 3. Time of Starting — 
Choosing a Ship. 4. Preliminary Arrangements. 5. Life at Sea. 6. Climate and Weather. 7. Management of 
t.:e Health at Sea. 8. Occupations and Amusements at Sea. 9. Objects of Interest at Sea. 10. End of the 
Voyage — Future Plans, n. The Homeward Voyage. 12. Australia: its Climate, Cities, and Health ResortB. 
13. South Africa and its Climate. 14. The Meteorology of the Ocean. 

Appendix A. — Outfit Required for a Voyage to Australia. B. Names and Addresses of some of the Principal 
Shipping Firms. 

"All the information is supplied by, or based upon, the actual experience of the author; and the book may be 
confidently recommended to all who have to undertake, without previous experience, a sea voyage of any length. 
Medical men may consult it with advantage, and commend it to those patients whom they may advise to try the 
effect of a long voyage at sea." — Medical Times and Gazette. 

" We have read every page of this book, and have derived both instruction and amusement." — Lancet. 

WELLS, OVARIAN AND UTERINE TUMORS. 

The Diagnosis and Surgical Treatment of Ovarian and Uterine Tumors. By 

T. Spencer Wells, m.d. [ To be issued shortly. 

So long a time having elapsed since Dr. Wells has collected the results of his 

large experience in book form, the present volume will be eagerly looked for by all 

interested in this very important subject. 

WOLFE, ON DISEASES OF THE EYE. 

A Practical Treatise on Diseases and Injuries of the Eye. Being a Course of 
Systematic and Clinical Lectures to Students and Medical Practitioners. By M. 
Wolfe, f.r.cp.e., Senior Surgeon to the Glasgow Ophthalmic Institution, etc. 
With 10 Colored Plates, and numerous other Illustrations. Octavo. Price $7.00 

WALKER, INTERMARRIAGE. 

Intermarriage, or, The Mode in which, and the Causes why, Beauty, Health 
and Intellect result from certain Unions ; and Deformity, Disease and Insanity 
from others. Illustrated. i2mo. Price $1.00 



PUBLICATIONS. 



43 



WOODMAN and TIDY, MEDICAL JURISPRUDENCE. 

Forensic Medicine and Toxicology.. By W. Bathurst Woodman, m.d., 
Physician to the London Hospital, and Charles Meymott Tidy, f.c.s., Pro- 
fessor of Chemistry and Medical Jurisprudence at the London Hospital. With 
Chromo-Lithographic Plates, representing the Appearance of the Stomach in 
Poisoning by Arsenic, Corrosive Sublimate, Nitric Acid, Oxalic Acid ; the Spectra 
of Blood and the Microscopic Appearance of Human and other Hairs ; and 
116 other Illustrations. Large octavo. 

Price, Cloth, $7.50; Medical Sheep, $8.50; Law Leather, $8.50 

" We have no hesitation in pronouncing the work to be one of unusual merit. More readable than Taylor, 
more systematic in its arrangement, and more practical in its instruction, it will prove to the medical jurist, not 
less than to the general practitioner, a storehouse of useful knowledge, conveyed in an unusually graphic style." — 
Dublin Journal of Medical Science. 

" The authors of this truly great work have largely supplied the want felt, sooner or later, by almost every 
doctor." — Cincinnati Lancet and Observer. 

"All the best known works on Medical Jurisprudence have been laid under contribution for the production of 
the present volume. It contains almost everything that can be found in other works on the subject; but it is no 
mere compilation. Dr. Woodman and Dr. Tidy have both thought out the subject for themselves, and, with rare 
industry and acumen, have brought together a mass of facts which is little short of astounding. The book is 
worthy to take its place alongside of any work on the same subject, and must prove of great use to all who prac- 
tice in criminal courts, and to all medical practitioners. We have no hesitation in recommending it to our read- 
ers." — London Lancet. 

"Altogether the work will rank with the best of its class as a medico-legal hand-book, and cannot fail to gain 
a wide popularity." — New York Medical Record. 

" It cannot be otherwise than a valuable contribution to the boundless subject of medical jurisprudence." — 
Albany Law Journal. 

"The scope of this book is very wide, and its execution worthy of all commendation." — Philadelphia Legal 
Intelligencer. 

WYTHE, ON THE MICROSCOPE. 

The Microscopist. A Manual of Microscopy and Compendium of the Micro- 
scopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and 
Practical Medicine. By Joseph H. Wythe, a.m., m.d. Fourth Edition. 252 
Illustrations. 8vo. Price, Cloth, $5.00; Leather, $6.00 

An Index and Glossary have been combined in this edition, so as to be a source 
of valuable information. Notices of recent additions to the microscope, together 
with the genera of microscopic plants, have been given in an Appendix. 



"From what we knew of the author of this work, as 
a skilled practical Microscopist, a successful teacher of 
the science, and a practitioner of medicine and surgery 
of long and varied experience, we had a right to expect 
agooofbookfrom his hands. Our expectations are fully 
realized in the volume before us. 'The style is clear 
and distinct, and one reads the book with the utmost 
facility of comprehension. It is the more valuable to 
the physician and medical student on account of its 
closer application of the microscope to medical subjects 
than we find elsewhere. The numerous plates, many 
of which are beautifully colored, are not to be excelled. 
We feel proud of it as an American production." — 
Pacific Medical and Surgical Journal. 



" This is one of the most valuable text-books on mi- 
croscopy ever offered to students or practitioners of 
medicine. This edition has been greatly enhanced in 
value by the addition of chapters on the use of the 
microscope in pathology, diagnosis, and etiology, and 
numerous new illustrations, some of which are from 
Rindfleisch. 

" The author very carefully brings out every neces- 
sary fact and principle relating to the use of the micro- 
scope, and now that this instrument has become an es- 
sential part of every practitioner's armamentarium, a 
practical guide and reference book is also a necessity, 
and we are fully warranted in reiterating the statement 
that this is one of the most valuable text-books ever 
offered to students and practitioners of medicine." — 
The Cincinnati Lancet and Clinic. 



BY SAME AUTHOR. 

DOSE AND SYMPTOM BOOK. Eleventh Edition. 

The Physician's Pocket Dose and Symptom Book. Containing the Doses and 
Uses of all the Principal Articles of the Materia Medica, and Original Prepara- 
tions. Eleventh Revised Edition. 

Price, Cloth, $1.00; Leather, with Tucks and Pocket, $1.25 

" The chapter on Dietetic Preparations will be found useful to all practicing physicians, most of whom have but 
little acquaintance with the mode of preparing the various articles of diet for the sick." — Boston Medical and 
Surgical Journal. 



" Many a hard-worked practitioner will find it a useful little work to have on his study table. 
and Surgical Journal. 



■Canada Medical 



44 PRESLEY BLAKISTON'S PUBLICA TIONS. 

WHEELER, MEDICAL CHEMISTRY. 

Medical Chemistry, Including the Outlines of Organic and Physiological 
Chemistry. By C. Gilbert Wheeler, m.d. Second Edition. i2mo. 

Price $3.00 
WOAKES, ON DEAFNESS AND GIDDINESS. 

On Deafness, Giddiness and Noises in the Head. By Edward Woakes, M.D., 
London, Surgeon to the Ear Department of the Hospital for Diseases of the 
Throat and Chest. Second Edition. Revised and Enlarged, with additional 
Illustrations. i2mo. Price $2.50 

" This book, although small, is evidently the result 
of much careful thought and observation. . . . We 



" The early demand for a fresh edition of Dr. 
Woakes' volume is a sufficient criticism of its merits. 
. . . No brief summary of his views could do full 
justice to the cogency and subtlety of his reasons. 
We prefer to commend the whole work to the thought- 
ful perusal of all intelligent medical practitioners who 
desire to rise above the level of mere routine empiri- 
cism." — Lancet, August 28th, 1880. 



cordially recommend the work as original and suggest- 
ive, and as being likely to prove very useful in explain- 
ing both the causation of symptoms otherwise puzzling, 
and their appropriate treatment." — Practitioner, July, 
1879. 



ILLUSTRATED BOOKS. 

MEDICINAL PLANTS. 

Being Descriptions, with original Figures, of the Principal Plants employed in 
Medicine, and an account of their Properties and Uses. By Robert Bentley, 
f.l.s., Professor of Botany in the King's College, and to the Pharmaceutical 
Society, and Henry Trimens, m.b., f.l.s., late Lecturer on Botany at St. 
Mary's Hospital Medical School. In 42 Parts, each, $2.00, or in 4 vols., large 
8vo, with 306 Colored Plates, bound in half morocco, gilt edged. $90.00 

AN ATLAS OF TOPOGRAPHICAL ANATOMY. 

After Plane Sections of Frozen Bodies. By William Braune, Professor of Anatomy 
in the University of Leipzig. Translated by Edward Bellamy, f.r.c.s., Sur- 
geon to and Lecturer on Anatomy at Charing Cross Hospital. With 34 Photo- 
lithographic Plates and 46 Wood cuts. Large imp. 8vo. $10.00 

ATLAS OF SKIN DISEASES. 

Consisting of a Series of Illustrations, with Descriptive Text and Notes upon 
Treatment. By Tilbury Fox, m.d., f.r.c.p., late Physician to the Department 
for Skin Diseases in University College Hospital. With 72 Colored Plates. 
In 18 Parts, each, $2.00 or, 1 Vol., Royal 4to, Cloth. $30^00 

AN ATLAS OF HUMAN ANATOMY. 

Illustrating most of the ordinary Dissections, and many not usually practiced by 
the Student. By Rickman J. Godlee, M.S., f.r.c.s., Assistant Surgeon to 
University College Hospital, and Senior Demonstrator of Anatomy in Universi- 
ty College. With 48 imp. 4to Colored Plates (112 Figures), and a volume of Ex- 
planatory Text. $30.00 

A COURSE OF OPERATIVE SURGERY. 

By Christopher Heath, f.r.c.s., Home Professor of Clinical Surgery in Uni- 
versity College, and Surgeon to the Hospital. With 20 Plates drawn from 
Nature by M. Leveille, and colored by hand under his direction. 4to. $14.00 

ILLUSTRATIONS OF CLINICAL SURGERY. 

Consisting of Plates, Photographs, Wood cuts, Diagrams, etc., etc., illustrat- 
ing Surgical Diseases, Symptoms, and Accidents ; also Operative and other 
Methods of Treatment, with Descriptive Letterpress. By Jonathan Hutchin- 
son, f.r.c.s., Senior Surgeon to the London Hospital. Vol. I, containing fas- 
ciculi I to X, bound, with Appendix and Index. $25.00 
Fasciculi XI to XIV. Ready. Each, $2.50 



The Microscopist. 

fottrtb: kditiost. 
WITH TWO HUNDRED AND FIFTY ILLUSTRATIONS, 

AND 

Greatly Enlarged by the Addition of oyer 200 Pages of New Matter. 
By J. H. WYTHE, A.M., M.D., 

Professor of Microscopy and Histology in the Medical College of the Pacific, 
San Francisco, California. 



This Manual of Microscopy aud Compendium of the Microscopic Sciences, 
Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and Practical Med- 
icine, in which the Practice of Medicine receives the largest attention, 
makes this work one of the most complete Text-Books known on the sub- 
ject. Matters of mere curiosity have been but briefly referred to, while 
every necessary fact or principle relating to the microscope has been care- 
fully stated and classified. 

The chapters on the use of the microscope in Pathology, Diagnosis, and 
Etiology, which have been added to this edition, have been largely illus- 
trated with wood-cuts from Rindfleisch. 

The Index and Glossary have been combined in this edition so as to be a 
source of valuable information, and notices of recent additions to the mi- 
croscope, together with the genera of microscopic plants, have been given 
in an Appendix. 

No pains have been spared to render this manual a useful companion to 
the student of Nature, and an aid to the progress of real science. Cloth, 
$5.00 ; Sheep, $6.00. 

"From what we knew of the author of this work, as a skilled practical Microscopist, 
a successful teacher of the science, and a practitioner of medicine and surgery of long 
and varied experience, we had a right to expect a good book from his hands. Our ex- 
pectations are fully realized in the volume before us. In a little over 400 pages he has 
condensed almost everything of importance relating to the subject. The style, though 
almost aphorismal, is clear and distinct, and one reads the book with the utmost facility 
of comprehension. It is the more valuable to the physician and medical student on 
account of its closer application of the microscope to medical subjects than we find else- 
where. Too much praise cannot be bestowed on the mechanical execution of the volume. 
The numerous plates, many of which are beautifully colored, are not to be excelled. 
Added to this, the large and clear type and the fine quality of paper make it a most 
comely book. We feel proud of it as an American production, dividing its authorship 
and execution between the extreme west and east territorial limits of the Republic." — 
Pacific Medical and Surgical Journal. 

"This is one of the most valuable text-books on microscopy ever offered to students or 
practitioners of medicine. This edition has been greatly enhanced in value by the ad- 
dition of chapters on the use of the microscope in pathology, diagnosis, and etiology, 
and numerous new illustrations, some of which are from Rindfleisch. 

" The author very carefully brings out every necessary fact and principle relating to 
the use of the microscope, and now that this instrument has become an essential part of 
every practitioner's armamentarium, a practical guide and reference book is also a ne- 
cessity, and we are fully warranted in reiterating the statement that this is one of the 
most valuable text-books ever offered to students and practitioners of medicine." — The 
Cincinnati Lancet and Clinic. 

V. BLAKISTON, SON & CO., Publishers, 

PHILADELPHIA. 



NOW READY, THE SEVENTH REVISED EDITION. 

MEIGS AND PEPPER, ON CHILDREN, 

THE MOST THOROUGH, COMPLETE AND PRACTICAL WORK 
ON THE SUBJECT NOW BEFORE THE PROFESSION. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILD- 
REN. By J. Forsyth Meigs, m.d., one of the Physicians to the Pennsylvania 
Hospital, Consulting Physician to the Children's Hospital, etc., and William 
Pepper, m.d., Professor of Clinical Medicine, University of Pennsylvania, Provost 
and ex-omcio President of the Faculty, Physician to the Philadelphia Hospital, 

Fellow of the College of Physicians, etc., etc. The Seventh Revised and Improved 

Edition. In one volume of over noo royal octavo pages. 

Price, handsomely bound in Cloth, $6.00; Leather, $7.00. 

The rapid sale of six large editions of Drs. Meigs and Pepper's work on Children, 
and the demand for the new edition now ready, is sufficient evidence of its great 
popularity. The large practice, of many years' standing, of the authors, imparts to it a 
value unequaled, probably, by any other on the subject now before the profession. 

The entire work has been now again subjected to an entire and thorough revision, 
some articles have been rewritten, many additions made, and great care observed by 
the authors, that it should be most effectually brought up to the light, pathological 
and therapeutical, of the present day. 

The publishers have very many favorable notices of the previous editions, re- 
ceived from numerous sources, foreign and domestic. They append a few from lead- 
ing journals, which will give a general idea of the value placed upon it, both as a 
Text-Book for the Student and a work of reference for the General Practitioner. 

" It is the most complete work upon the subject in our language ; it contains at once the results of personal and 
the experience of others ; its quotations from the most recent authorities, both at home and abroad, are ample, and 
we think the authors deserve congratulations for having produced a book unequaled for the use of the student, 
and indispensable as a work of reference for the practitioner." — American Medical yournal. 



" But as a scientific guide in the diagnosis and treatment of the diseases of children, we do not hesitate to say 
that we have seldom met with a text-book so complete, so just, and so readable, as the one before us, which in its 
new form cannot fail to make friends wherever it shall go, and wherever great erudition, practical tact, and fluent 
and agreeable diction are appreciated." — American yournal of Obstetrics. 



" It is only three years since we had the pleasure of recommending the Fifth Edition of this excellent work. 
With the recent additions it may safely be pronounced one of the best and most comprehensive works on diseases 
of children of which the American Practitioner can avail himself, for study or reference.'' — N. Y. Med. yournal. 



" It is not necessary to say much, in the way of criticism, of a work so well known. But it is clinical. Like so 
many other good American medical books, it marvelously combines a rtsum& of all the best European literature 
and practice, with evidence throughout of good personal judgment, knowledge, and experience. The book also 
abounds in exposition of American experience and observation in all that relates to the diseases of children. We 
are glad to add it to our library. There are few diseases of children which it does not treat of fully and wisely, in 
the light of the latest physiological, pathological, and therapeutical science." — London Lancet. 

P. BLAKISTON, SON & CO., Publishers, 

Successors to LINDSAY & BLAKISTON, 

1012 WALNUT STREET, PHILADELPHIA. 




JANUARY, 1882. 



HANDBOOKS FOR PHYSICIANS, 



AT GREATLY REDUCED PRICES. 



Realizing the demand for compact, well written Handbooks 
at a low price, upon the several branches of Medicine and Sur- 
gery, adapted at once to the wants of Junior Practitioners and 
Students of Medicine as well as those Physicians of more ad- 
vanced Practice who have not the leisure to read or do not care 
to purchase the larger and more expensive works, the subscri- 
bers propose re-issuing the following books, at a GREATLY 
REDUCED PRICE. 

Each book is a distinct treatise upon its Individual Subject, by 
well known authors, and whenever ILLUSTRATIONS are of 
value or give interest to the subject they are inserted. Each book 
can be purchased SEPARATELY at the low price named, or 
when five or more volumes are ordered and remitted for at one 
time a discount is allowed, (see special offer, page 4), and they 
will be mailed free of postage. 

The Publishers trust, in offering these books on these most 
favorable terms, that, while supplying a higher class of Medical 
Literature at such a nominal price, and in a form WORTHY of 
PRESERVATION in the LIBRARY, their sale may be greatly 
extended and their efforts appreciated by the Profession. 

P. BLAKISTON, SON & CO., 

1012 WALNUT STREET, 

PHILADELPHIA. 



HANDBOOKS FOR PHYSICIANS. 



ATHILL'S DISEASES OF WOMEN. FIFTH EDITION, WITH ILLUSTRATIONS. 

Diseases Peculiar to Women. Clinical Lectures. By Lombe Athill, m.d., 
Consulting Obstetric Surgeon to the Adelaide Hospital, Dublin;. Ex- 
President of the Dublin Obstetric Society, etc., etc. Fifth edition, revised 
and enlarged, with thirty-five illustrations. i2mo, 342 pages. 

Price, handsomely bound in Cloth, $1.25 

" neatly bound with Paper Covers, .75 
" The work is one of great value to the general practitioner. All theory, hypothesis, and 
scientific speculation is omitted, and only the really practical part of Gynaecology discussed. By 
its condensed arrangement it will prove useful to the experienced specialist, while to the advanced 
student and general practitioner it will be found a valuable and convenient work." — American 
Journal of Obstetrics. 

"Asa handy text-book of the diseases of women for general practitioners it has neither peer 
nor rival. Its information is trustworthy and practical, and written in a style terse, unaffected, 
and intelligible." — Obstetrical Journal of Great Britain and Ireland. 

DAY ON HEADACHES, third edition, with ILLUSTRATIONS. 
The Nature, Causes, and Treatment of Headaches. By William Henry Day, 
m.d., Physician to Samaritan Hospital for Women and Children, etc. 
Third Edition, with a Large, Full-page Frontispiece, illustrating the 
cerebal cells of a healthy brain, and many other illustrations. 
Summary of Contents. — Headache from Cerebral Anaemia, Cerebral Hyperemia, Sym- 
pathetic, Congestive, Dyspeptic or Bilious Headaches, Headache from Plethora, from Exhaus- 
tion, from Change in Cerebral Tissue, from Affections of the Periosteum, Nervous and Nervo- 
Hyperagmic Headache, Toxsemic, Rheumatic, Arthritic or Gouty Headache, Neuralgic Head- 
ache, and Headaches of Childhood, Early and Advanced Life. 

One volume, i2mo, 322 pages. Price, handsomely bound in Cloth, £1-25 

" neatly bound with Paper Covers, .75 
li The chief value of the work consists in the wealth of resources at the command of the 
author, and the practical value of his therapeutic suggestions." — New York Medical Record. 

" No practitioner could read it without obtaining many a hint of value to him in his daily 
work." — Westminster Review. 

.CHARTERIS' PRACTICE OF MEDICINE, with numerous m IC roscopic 

AND OTHER ILLUSTRATIONS. 

A Handbook of the Practice of Medicine, with an Appendix containing 
valuable Formulae and a complete Index. By M. Charteris, m.d., Mem- 
ber of the Hospital Staff and Professor in the University of Glasgow. 
With Microscopic and other Illustrations. One volume. i2mo. 336 
pages. Price, handsomely bound in Cloth, #1-25 

" neatly bound with Paper Covers, .75 
" It is well arranged, admirably condensed, and thoroughly practical." — Medical Record. 
" It reveals the author as a physician of large attainments and experience, and the rare capa- 
city of briefly stating what is essential to be known. It is valuable to students, as it clearly out- 
lines to them interesting subjects of investigation, and to physicians, by refreshing their memo- 
ries on subjects to which they may not have recently given special attention." — Chicago Journal 
and Examiner. 



HABERSHON ON THE DISEASES OF THE STOMACH. 

The Varieties of Dyspepsia : Their Diagnosis and Treatment. By S. O. 
Habershon, m.d., f.r.c.p., Senior Physician to, and late Lecturer on the 
Principles and Practice of Medicine at, Guy's Hospital. Third Edition, 
Revised. One volume, large i2mo, 324 pages. 

Price, handsomely bound in Cloth, 1 1.25 

" neatly bound with Paper Covers, .75 
"As an expression of the results of long personal experience in both hospital and private 
practice, conveyed in agreeable though not always perspicuous diction, this contribution of Dr. 
Habershon's has special value of its own, and is so far entitled to the favorable consideration of 
the practitioner, as is already testified by a demand for a third edition." — American Journal of 
Medical Science. 

" We can cordially recommend this book of Dr. Habershon's to the profession."— -Medical 
Record. 



A T GREA TL Y RED UCED PRICES. 



BLACK'S REPRODUCTIVE ORGANS. 

On the Functional Diseases of the Renal, Urinary and Reproductive Organs, 
with a general review of Urinary Pathology. By D. Campbell Black, 
m.d., l.r.c.s., Edin., Member of the General Council of the University 
of Glasgow. One volume, 1 2mo. 300 pages. 

Price, handsomely bound in Cloth, #1.25 

" neatly bound with Paper Covers, .75 
This excellent work contains a complete summary of the most advanced views on " The 
Conditions that Affect the Secretion of Urine, with Special Reference to Suppression," " Re- 
tention of Urine, its Varieties, Causes and Treatment," and " Irritable Bladder and Strangury," 
and embraces the entire subject of Spermatorrhoea and its accompanying disorders." — New 
York Medical Record. 

KIDD'S LAWS OF THERAPEUTICS. 

The Laws of Therapeutics, or The Science and Art of Medicine. By Joseph 
Kidd, m.d. One volume, i2mo. 196 pages. 

Price, handsomely bound in Cloth, $1-25 

" neatly bound with Paper Covers, .75 
" Dr. Joseph Kidd was Lord Beaconsfield's medical adviser, and an eminent physician of the 
regular school. In this work he briefly but clearly sketches the history of medicine from the 
earliest period, and shows that the chief mistakes have been made through deference to theory 
and negligence of the teaching of facts. The high standing of the author will give weight to 
his views. The volume deserves the attention of physicians of all schools. Like a sensible 
practitioner, he does not allow himself blindly to follow any, but seeks out the causes of disease, 
and tries by rational measures to remove it." — London Practitioner. 

SEWELL'S MANUAL OFDMTAL ANATOMY AND SURGERY. 

Including the Extraction of Teeth, and much other information of value to 
Country Physicians, in relation to the Mouth and Teeth. By H. E. 
Sewell, d.d.s., m.d. One volume, i2mo. 203 pages and 77 Engrav- 
ings. Price, handsomely bound in Cloth, $1-25 

" neatly bound with Paper Covers, .75 
" A valuable book for the general practitioner who is in want of a practical manual relating 
especially to diseases of the teeth." — Medical Brief. 

" It will be found useful to the general practitioner in the management of many incidental 
affections connected with the teeth and mouth, which canno always be handed over to the 
specialist." — Pacific Medical journal. 

HEATH'S SURGICAL DIAGNOSIS. 

A Guide to Surgical Diagnosis, and Companion Volume to "Heath's 
Minor Surgery." By Christopher Heath, f.r.c.s., etc., etc. One 
volume, i2mo, 214 pages. Price, handsomely bound in Cloth, $1-25 

" neatly bound with Paper Covers, .75 
" This essay on Surgical Diagnosis groups surgical affections anatomically, and the sjmptoms 
of each disease in the order in which they would strike a close observer. The whole field of 
surgery is included, differential points being prominently brought into light, often by means of 
a tabular method. It is, indeed, the most satisfactory book of the class which has come to our 
notice. The author is both a skillful surgeon and a finished writer." — Medical and Surgical 
Reporter. 

CARTER ON THE EYESIGHT, fifty illustrations, with test 

TYPES, ETC. 

Eyesight, Good and Bad. A Treatise on the Exercise and Preservation of 
Vision. By Robert Brudenell Carter, f.r.c.s., Ophthalmic Surgeon 
to St. George's Hospital. Second Edition, with 59 Illustrations, Test 
Types, etc. One volume, i2mo, 272 pages. 

Price, handsomely bound in Cloth, $1.25 

" neatly bound with Paper Covers, .75 

" It is written in a lucid and agreeable style, conveying an easily comprehensible account of 

the structure of the eye and the function of vision, and gives a description of the principal 

anomalies of the latter, at the same time inculcating such salutary advice as may be beneficial 

for the preservation of sight." — London Medical Times and Gazette. 



HANDBOOKS FOR PHYSICIANS. ~\ Q 

FENWICK'S PRACTICE OF MEDICINE. 

Outlines of the Practice of Medicine, with special reference to the Prognosis 
and Treatment of Disease. With Appropriate Formulae and Illustrations. 
By Samuel Fenwick, m.d., Lecturer on the Principles and Practice of 
Medicine and Physician to the London Hospital. One volume, large 
i2mo. 387 pages and Illustrations. 

Price, handsomely bound in Cloth, $1-25 

" neatly bound with Paper Covers, .75 
" This work displays a sound judgment in the arrangement of its subject matter, and an in- 
timate acquaintance with the practice of medicine possessed by but few writers. Of all the 
handbooks we have seen, this is certainly one of the best." — Medical Herald. 

" It is an eminently practical treatise, pervaded with much common sense, and will doubtless 
be found useful, particularly by advanced students." — Boston Medical and Surgical Journal. 

GALLABIN'S STUDENT'S GUIDE TO THE DISEASES OF WOMEN. 

SIXTY-THREE ILLUSTRATIONS. 

By Alfred A. Gallabin, m.d., Obstetric Physician and Lecturer on Obstet- 
ric Medicine at Guy's Hospital. One volume, i2mo, 370 pages and 
63 Illustrations. Price, handsomely bound in Cloth, #1-25 

" neatly bound with Paper Covers, .75 
" Among all the various works on diseases of women with which we are acquainted, there is 
none which so nearly approaches the perfection of what a student's text-book should be. . . 
. . The work is well illustrated." — Students' Journal. 

" Its style is clear, elegant and concise. It contains a great amount of information; indeed, 
we do not think the student or practitioner will find any book which will convey to him in so 
small a compass so much accurate knowledge about the pathology and diagnosis of the diseases 
peculiar to women." — Medical Times and Gazette. 

LEWIN ON SYPHILIS. WITH ILLUSTRATIONS. 

The Treatment of Syphilis with Subcutaneous Sublimate Injections. By Dr. 
George Lewin, Surgeon-in-Chief of the Syphilitic and Skin Disease 
wards of the Charite Hospital, Berlin. Translated by Dr. Carl Prcegler, 
and Dr. E. H. Gale, late Surgeons United States Army. One volume, 
i2mo, 250 pages. Price, handsomely bound in Cloth, #1.25 

" neatly bound with Paper Covers, .75 
" Dr. Lewin's volume has a special value, as giving the results of the author's very large ex- 
perience in the treatment of syphilis by the hypodermic use of mercury. Over seventy clinical 
histories are given in detail, and the results certainly seem to warrant the conclusion that, in the 
subcutaneous injection of mercury, a powerful and efficient remedy has been found, with which 
the surgeon may hopefully combat cases of syphilis which have resisted other modes of treat- 
ment." — American Journal of Medical Science. 

" The vast experience of the author at The Royal Charit6 Hospital, in Berlin, where all the 
patients are sent to him for treatment who have syphilis, gives his words great weight and con- 
sideration." — Virginia Clinical Record. 



JJ@P* All the above books are printed with a clear and distinct type, on good paper, and well 
bound. Most of them are illustrated with wood cuts and other engravings. 

SPECIAL OFFER. 

They will be sold separately, and mailed, postage prepaid, upon the receipt of the prices 
annexed. 

Five or more volumes, in cloth, if ordered and remitted for at one time, will be mailed, 
postage prepaid, at one dollar each. 

Five volumes or more, in paper covers, if ordered and remitted for at one time, will be 
mailed, postage prepaid, at sixty cents each. 

P. BLAKISTON, SON & CO., 

(SUCCESSORS TO LINDSAY * BLAKISTON) 

No. 1013 WALNUT STREET, PHILADELPHIA, jQ& 



llBlHIl ° F C0NGRESS 

022 194 769 1 



